We  am  not  stay  amid  the  ruins." — Emhrson 


t^        5^         «<?* 


PPCSENT 
STATUS  * 
PEDIATPICS 


EDITED  BY 

Benjahin  r.  Btxilcv,  n.  D.,  Lincoln,  Nebraska 
Allison  Clokev,  M.  D.,  Louisville,  Kentucky 


;;?•/    r:'J^^6 

Wi 

J '  •  »*  •* 
>  1  *». 

\.^l^Rf^K' 

» 

STATE   JOURNAL  COMPANV 

LINCOLN,  NEB. 

\z 


g-u^Tj^ 


COPYRIGHTED   BY 


BENJAMIN  F.  BAILEY 
ALLISON   CLOKEY, 


CONTRIBUTORS. 


Benjamin  F.  Bailey,  M.  D.,  Lincoln,  Nebraska,  Chairman  Sec- 
tion of  Paedology,  American  Institute  of  Homoeopathy, 
1896;  ex-President  Nebraska  State  HonKjeopathic  Medical 
Society ;  Member  Nebraska  State  Board  of  Health :  Diph- 
theria and  Scarlet  Fever. 

Howard  Roy  Ciiislett,  M.  D.,  Chicago,  Illinois,  Professor  of 
Surgery  in  Hahnemann  College  and  Hospital,  Chicago; 
Attending  Surgeon  to  Hahnemann  and  Cook  County  Hos- 
pitals: Surgical  Diseases  of  Children. 

Allison  Clokey,  M.  D.,  Louisville,  Kentucky,  Secretary  Sec- 
tion of  Paedology,  American  Institute  of  Homoeopathy, 
1896;  President  Kentucky  State  Homoeopathic  Society; 
Registrar  and  Professor  of  Physiology,  Southwestern 
Homoeopathic  Medical  College:  Typhoid  and  Remittent 
Fever. 

Joseph  Pettee  Couh,  M.  D.,  Chicago,  Illinois,  Professor  of 
Pediatrics,  Hahnemann  Medical  College  and  Hospital ; 
Registrar  of  Hahnemann  Medical  College:  Diathetic  Dis- 
eases. 

C.  D.  Crank,  M.  D.,  Cincinnati,  Ohio,  Emeritus  Professor  of 
Pediatrics,  Pulte  Medical  College:   Cholera  Infantum. 

Martin  Deschere,  M.  D.,  New  York,  N.  Y.,  Professor  of  Pe- 
diatry, New  York  Homoeopathic  Medical  College:  Diseases 
of  the  Brain,  including  Cerebro-Spinal  Meningitis. 

Mark  Edgerton,  Kansas  City,  Missouri,  Professor  of  Materia 
Medica,  Kansas  City  Homoeopathic  Medical  College:  Mi- 
nor Infectious  Diseases. 


443351 


IV  CONTRIBUTORS. 

Lemuel  C.  Grosvenor,  M.  D.,  Chicago.  Illinois,  Professor  of 
Obstetrics  and  Sanitary  Science,  Chicago  Homoeopathic 
Medical  College:  The  New-Born  and  Infant  Diet. 

Alfred  P.  Hanchett,  M.  D.,  Council  Bluffs,  Iowa:  Urinary- 
Diseases. 

William  E.  Leonard,  M.  D.,  INIinneapolis,  Minnesota,  Professor 
of  Materia  Medica  and  Therapeutics  in  the 'Homoeopathic 
Medical  Department  of  the  State  University  of  Minnesota; 
Diseases  of  the  Digestive  Tract. 

A.  M.  Linn,  M.  D.,  Des  Moines,  Iowa,  Member  American  In- 
stitute of  Homoeopathy;  Member  Hahnemann  Association 
of  Iowa;  Physician  to  Home  of  Friendless  Children,  of 
Des  Moines,  Iowa:  Skin  Diseases. 

George  B.  Peck,  ^I.  D.,  Providence,  Rhode  Island:  Statistics. 

Edward  R.  Snader,  M.  D.,  Philadelphia,  Pennsylvania,  Lec- 
turer on  Physical  Diagnosis,  Hahnemann  Medical  College ; 
Corresponding  Secretary  of  Pennsylvania  State  Homceo- 
pathic  Society:  Thoracic  Diseases. 

Eugene  F.  Storke,  M.  D.,  Denver,  Colorado,  Professor  of 
Principles  and  Practice,  and  Registrar  Denver  Homceo- 
pathic  Medical  College:  Diseases  of  the  Spine. 

C.  A.  Weirick,  M.  D..  Chicago,  Illinois,  ex  President  Illinois 
Homoeopathic  State  Medical  Association ;  ex-President 
Homoeopathic  Medical  Society  of  Chicago;  Adjunct  Pro- 
fessor of  Physiology,  Chicago  Homoeopathic  Medical  Col- 
lege: Reflexes. 

These  contributors  are  members  of  the  Section  of 
Paedology  of  the  American  Institute  of  Homoeopathy 
for  the  year  1896. 


CONTENTS. 


PAGES 

Chapter    I — The   New-Born   and    Infant    Diet,  by    L.  C. 

Grosvenor,  M.  D 1-7 

First  Toilet,  i  ;  Later  Toilet,  2  ;  Asphyxia,  3  ;  Ophthal- 
mia, 3  ;  Malformations,  3  ;  Diet,  3  ;  Bathing,  4  ;  Sleep, 
5 ;  The  Care  of  the  Mother,  5 ;  Artificial  Feeding,  6. 
Chapter  II — Diathetic  Diseases,  by  Joseph  Pettee  Cobb, 

M.  D 8-55 

Rhachitis,  8;  Rheumatism,  16;  Syphilis,  23;  Tubercu- 
losis, 36. 

Chapter  III — Reflexes,  by  C.  A.  Weirick,  M.  D 56-72 

Chapter  IV — Diseases  of  the  Brain,  including   Cerebro- 
spinal Meningitis,  by  Martin  Deschere,  M.  D. .  .73-113 
Simple  Meningitis,   73 ;  Tubercular  or  Basilar  Menin- 
gitis, 78;  Cerebro-Spinal  Meningitis,  84;  Chronic  Hy- 
drocephalus, 8g ;  Convulsions,  92  ;  Epilepsy,  97;  Rep- 
ertory of  Characteristics,  104. 
Chapter  V — Diseases  of  the  Spinal  Cord,  by  Eugene  F. 

Storke,  M.  D 1 14-125 

General  Considerations,    114;    Poliomyelitis   Anterior, 
115;   Acute    Myelitis,    117;    Chronic    Myelitis,    n8; 
Landry's   Paralysis,   118;    Syringomyelia,   119;    He- 
reditary Ataxia,  119;  General  Treatment,  120. 
Chapter  VI — Thoracic  Diseases,  by  Edward  R.  Snader, 

M.  D 126-150 

General  Considerations,  126;  Trachitis,  127;  Bronchitis, 
127;  Broncho-Pneumonia,  130;  Lobar  Pneumonia, 
133;  Pulmonary  Tuberculosis,  135;  Asthma,  136; 
Pleuritis,   137;    Purulent  Pleuritis,   138;    Diseases  of 


VI  CONTENT?. 

PAGES 
Heart,   140;  Functional  Diseases  of  Heart,  142;  Or- 
ganic Diseases,  142;  Endocarditis,  144;  Chronic  En- 
docarditis,   145;  Myocarditis,  147;  Diseases  of  Peri- 
cardium, 147. 

Chapter  VH — Diseases  of  the  Digestive  Tract,  by  Wm. 

E.  Leonard,  M.  D 151-1S1 

Catarrhal  vStomatitis,  152;  Ulcerative  Stomatitis,  153; 
Aphthous  Stomatitis,  154;  Membranous  Stomatitis, 
155;  Thrush,  155;  Cancrum  Oris,  157;  Dentition, 
157;  Dyspepsia,  160;  Chronic  Dyspepsia,  161;  Acute 
Gastritis,  162;  Chronic  Gastritis,  163;  Vomiting,  164; 
Icterus,  165;  Diarrhoea,  167;  Entero-Colitis,  170;  Di- 
arrhoea of  Bacterial  Origin,  173;  Constipation.  174; 
Intestinal  Parasites,  176;  Oxyuris  Vermiculosis,  177; 
Ascaris  Lumbricoides,  17S;  Trichocephalus  Dispar. 
iSo;  Tape  Worm,  180. 

Chapter  VIII — Diseases  of  the  Urinary  Organs,  by  Alfred 

P.  Hanchett,  M.  D 182-195 

The  Urine,  182;  Functional  Diseases  of  Bladder,  1S4; 
Enuresis,  187;  Lithemia,  189;  Renal  Calculi,  191; 
Acute  Nephritis,  192;  Diabetes  Mellitus,  193;  Dia- 
betes Insipidus,  194. 

Chapter  IX — Skin  Diseases,  by  A.  M.  Linn,  M.  D.  .  .  .196-215 
Erythema,  196;  Roseola,  198;  Urticaria,  199;  Vesicu- 
\se,  200;  Ecthyma,  203;  Impetigo,  204  ;  Prurigo,  205  ; 
Psoriasis,  206;  Naevus,  206;  Lentigo,  207;  Leuco- 
derma,  207;  Acne,  208;  Lupus,  209;  Molluscum,  209; 
Verrucse,  210;  Scabies,  210;  Syphiloderma.  211; 
Tinea  Favosa,  213;  Tinea  Tonsurans,  214. 

Chapter  X — Minor  Infectious  Diseases,  by  Mark  Edger- 

ton,  M.  D 216-224 

Measles  or  Rubeola,  216;  Varicella,  219;  Rubella- 
Rbtheln,  220;  Differential  Diagnosis,  221;  Parotitis, 
222 ;  Pertussis,  223. 

Chapter  XI — Cholera  Infantum,  by  Chas.  D.  Crank,  M.  D., 

225-237 


CONTENTS.  Vll 

PAGES 

Chapter  XII — Diphtheria  and  Scarlet  Fever,  by  Benj.  F. 

Bailey,  M.  D 238-258 

Diphtheria,  238 ;  Scarlet  Fever,  249. 

Chapter  XIII— Typhoid  and  Remittent  Fever,  by  Allison 

Clokey,  M.  D 259-265 

Chapter  XIV — Orthopedic  Surgery,  by  Howard  Roy  Chis- 

lett,  M.  D 266-297 

General  Considerations,  266;  Torticollis,  270;  Scoliosis, 
272;  Pott's  Disease,  277;  Talipes,  282;  Contractures 
and  Ankyloses,  290;  Genu  Valgum  and  Genu  Varum, 
292. 

Chapter  XV— Statistics,  by  Geo.  B.  Peck,  M.  D 298-303 


PREFACE. 


In  presenting-  this  book  to  the  profession,  we  have 
not  attempted  to  prepare  a  text-book  or  a  complete 
reference  book,  but  simply  what  its  title  indicates — a 
resume  of  the  present  status  of  pediatrics.  We  be- 
lieve that  this  subject,  which  was  so  dear  to  the  fathers 
of  our  school,  and  which  has  been  in  our  practice  the 
entering-  wedge  for  many  a  conversion  to  our  tenets 
and  beliefs,  has  been  of  late  years  sadly  neglected. 
Through  this  little  volume  it  is  our  desire  to  arouse 
fresh  interest  in  Pediatrics,  and  to  take  this  opportu- 
nity to  urge  every  member  of  the  homoeopathic  pro- 
fession to  put  himself  in  close  touch  with  the  work 
by  placing  upon  his  shelves,  not  bye-and-bye,  but  im- 
mediately, all  of  the  recent  homoeopathic  works  upon 
diseases  of  children.  It  is  due  to  those  who  have 
done  earnest  and  honest  work  in  this  line  that  they  be 
rewarded  by  financial  appreciation.  Fisher's  Dis- 
eases of  Children  is  a  complete  and  thoroughly 
praiseworthy  work,  and  no  practitioner  can  complete 
his  library  on  modern  pediatrics  without  it.  Tooker 
on  the  same  subject  is  a  fit  companion  piece.  If  we 
are  successful  in  bringing  to  the  authors  and  publish- 
ers of  our  late  works  on  pediatrics  renewed  recogni- 
tion, and  in  awakening  in  our  societies  in  general,  and 


X  PREFACE. 

in  the  American  Institute  in  particular,  an  enthusi- 
asm in  the  study  of  the  diseases  of  the  babes  of  the 
world,  we  shall  feel  that  our  work  is  repaid  and  that 
we  have  at  least  done  our  little  toward  a  fitting  me- 
morial this  centennial  year.  The  incentives  that 
have  been  ours  during  this  work  have,  we  believe,  be- 
longed in  truth  to  each  contributor  to  this  book,  and 
we  wish  here  to  publicly  and  most  gratefully  thank 
each  contributor — all  bus}^  men — for  the  untiring  help 
and  courtesy  that  have  at  all  times  been  ours. 

THE  EDITORS. 
Lincoln,  Nebraska, 

June  io,  i8g6. 


CHAPTER  I. 


THE  NEW-BORN  AND  INFANT  DIET. 

BY  LEMUEL  C.  GROSVENOR,  M.  D. ,  PROFESSOR  OF  OBSTETRICS  AND 
SANITARY  SCIENCE,  CHICACiO  HOMtt:OPATHIC  MEDICAL  COL- 
LEGE,   CHICAGO. 

First  Toilet. — The  first  thing  which  interests  us, 
even  before  the  cord  is  severed,  is  baby's  first  toilet. 
On  coming  into  the  world  baby  is  covered  with  four 
substances, — amniotic  fluid,  the  mucous  lubricants  of 
the  vagina,  blood,  and  vernix  caseosa.  The  first  three 
of  these  are  readily  removed,  while  wet,  with  a  soft 
towel,  and  then  the  baby  is  oiled  with  warm  sweet  oil 
to  soften  the  wax.  After  the  oil  has  remained  on  two 
or  three  minutes  the  fourth  coat  is  easily  removed, 
leaving  the  baby  with  a  soft,  clean,  velvety  skin,  no 
soap  or  water  having  been  used.  The  old  teaching 
that  baby  should  lie  about  for  half  an  hour  and  all 
these  substances  allowed  to  dry  on,  seems  to  us  a 
pernicious  one. 

To-day  the  dressing  for  the  cord  is  absorbent  cot- 
ton rather  than  the  historic  burnt  linen  of  former 
years.  This  makes  a  soft,  kind,  antiseptic  pad  for 
the  navel.  The  band  should  be  as  simple  as  possible 
— a  single  thickness  of  flannel,  without  hems,  em- 
broidery, or  hand  painting.  Remember  always  that 
the  only  purpose  of  this  bandage  is  to  retain  the 

2  (I) 


2  PRESENT    STATUS    OF    PEDIATRICS. 

navel  dressing,  and  it  is  to  be  thrown  away  when  the 
cord  comes  off.  To-day  we  recognize  the  fact  that 
the  band  of  the  pinning  blanket  and  skirt,  together 
with  the  navel  bandage,  are  the  fruitful  causes  of 
ruptures,  the  teachings  of  the  past  to  the  contrary 
notwithstanding. 

Later  Toilet. — The  old  diaper,  nearly  a  yard 
square  and  folded  so  many  times,  is  a  cruel  one  to 
baby,  overheating  the  hips  and  the  kidneys,  and  re- 
taining so  closely  the  liquid  and  solid  excreta,  w^ith 
their  emanations,  as  to  cause  frequent  excoriations  of 
the  parts.  The  new  double  diaper,  eighteen  inches 
square  and  ten  inches  square,  gives  ample  protection 
and  is  much  more  kindly. 

Among  the  more  intelligent  mothers  and  physi- 
cians, the  chemise,  pinning  blanket,  and  the  skirts 
with  their  bands  are  discarded  and  in  their  place 
comes  the  beautiful  princess  cut  Gertrude  suit.  This 
leaves  all  the  organs  in  the  body  as  free  to  play  their 
part  as  in  the  colt  or  kitten.  Probably  40, 000  babies 
are  in  this  suit  to-day.  No  one  can  educate  the  young 
mothers  of  the  land  in  these  better  ways  as  well  as 
the  physician.  The  wide-awake,  up-to-date  doctor, 
rather  than  grandmother,  should  be  consulted  by  the 
young  mother  in  these  matters.  This  simple  first 
toilet  being  completed,  the  baby  should  be  laid  away 
in  a  warm  nest  for  rest. 

Asphyxia. — Should  baby  be  born  asphyxiated, 
from  long  impaction  in  the  straits,  perhaps  no  one 
thing  is  so  promptly  available  to  restore  the  child  as 
the  hot  bath.  If  the  cord  has  not  ceased  beating, 
this  bath  should  be  given  before  severing  the  cord. 


THE    NEW-BORN    AND    INFANT    DIET.  3 

This  is  accomplished  by  placing  the  pan  between  the 
mother's  knees,  and  placing  the  baby  all  over  in  the 
bath  as  hot  as  it  can  be  borne,  every  few  moments 
adding  more  hot  water.  Here  the  baby  is  handled, 
expanding  and  compressing  the  chest  to  imitate  res- 
piration. This  hot  bath  keeps  the  blood  limpid,  the 
body  warm,  and  we  are  soon  rewarded  by  seeing  our 
baby  revive.  In  desperate  cases  the  finger  may  be 
lubricated,  and  the  baby's  rectum  dilated  therewith — 
this  will  often  provoke  respiration  in  seemingly  hope- 
less cases. 

Ophthalmia  of  new-born  infants  may  be  prevented 
by  immediately  making  the  eyes  absolutely  clean  by 
a  warm  solution  of  boracic  acid.  Remember  always 
that  a  prolific  cause  of  this  disease  is  the  poisonous 
vaginal  secretions  to  which  the  eyes  are  exposed  in 
their  passage  into  the  world.  The  cleansing  antisep- 
tic vaginal  douche  in  thd  early  part  of  the  labor  will 
save  much  after  trouble  in  this  direction. 

Malformations.— Early  in  the  case  the  doctor 
should  examine  the  baby  from  head  to  feet  for  any 
evidences  of  malformation  or  disease.  An  occluded 
rectum,  a  hypospadias,  a  spina-bifida,  a  harelip,  or 
cleft  palate,  pluro  or  syndactylism  should  not  escape 
his  notice.  Many  of  the  minor  abnormalities  may 
be  corrected  without  the  knowledge  of  the  mother. 

Diet. — Perhaps  no  one  thing  is  doing  so  much  to 
prevent  diarrhoea,  dysentery,  and  summer  complaint, 
which  so  mark  the  first  two  years  of  baby  life,  as  reg- 
ular feeding.  To-day  we  know  that  the  old  teaching, 
''little  and  often,"  is  a  bhmder,  and  the  advanced 
physi«"ian  gives  to  the  young  mother  valuable  lessons 


4  PRESENT    STATUS    OF    PEDIATRICS, 

in  this  regard.  The  young  mother  is  given  this  form- 
ula,— nurse  the  baby  every  three  hours  during  the 
day  and  once  in  the  night  for  the  first  three  months, 
then  every  four  hours,  and  never  again  in  the  night 
for  the  balance  of  the  nursing  period.  Some  of  the 
beautiful  results  of  this  better  way  are  found  to  be 
these, — colics  disappear  entirely,  vomiting  ceases, 
baby  has  two  stools  a  day  instead  of  six,  stools  are 
wholesome  and  well  digested ;  there  is  no  cholera  in- 
fantum next  summer  and  no  "teething"  by  and  by. 
This  regular  habit  should  be  instituted  the  first  day 
and  not  wait  till  the  third  day  when  the  milk  comes. 
Why  should  we  tease  the  baby  or  annoy  the  mother 
before  the  milk  comes?  For  three  excellent  reasons. 
In  the  first  place,  the  baby  is  learning  how  and  get- 
ting used  to  nursing;  secondly,  early  nursing  pro- 
vokes uterine  contractions  and  prevents  subinvolution 
of  the  uterus ;  third,  the  breasts  contain,  right  at  first, 
a  few  drops  of  cholostrum,  which  act  as  a  cathartic 
for  baby.  In  this  matter  of  regular  nursing  do  not 
consult  the  baby  in  the  least,  ask  the  clock.  Expe- 
rience proves  that  these  regularly  fed  babies  are 
larger,  healthier,  happier,  than  those  who  eat  when 
they  want  it,  and  hang  on  the  breast  all  night.  Cry- 
ing for  food  ceases  entirely,  unless  you  go  past  the 
regular  hour.  Regular  nursing  and  the  new  dress 
have  done  very  much  to  reduce  infantile  mortality. 

Bathing". — The  daily  full  bath,  immersing  the  baby 
all  over  in  the  warm  water,  washing  it  from  head  to 
foot  without  soap,  drying  it  in  a  warm  receiving 
blanket,  dressing  it  quickly  in  the  warm  Gertrude 
suit,  is  another  great  advance  over  old  methoHs.     It 


THE    NEW-BORN    AND   INFANT    DIET.  5 

is  easily  done  in  seven  minutes,  instead  of  forty-five 
minutes  the  old  way.  This  bath  should  occur  on  an 
empty  stomach,  before  nursing  rather  than  after.  A 
good  time  is  just  before  the  second  nursing  of  the 
day.  This  kindly,  soothing,  full  bath  makes  baby 
contented  and  happy  for  all  day. 

Sleep,  that  boon  to  baby  life,  is  to-day  receiving 
much  more  attention  than  formerly.  Regular  habits 
here  are  worth  as  much  as  in  feeding.  Then  the 
Creator's  two  great  conditions  of  rest  the  world  over, 
darkness  and  quiet,  should  be  observed.  A  simple 
couch,  without  a  pillow,  light  covering,  and  pure  air 
are  conditions  of  sweetest  rest. 

The  Care  of  the  Mother. — Many  babies  die  every 
year  from  nursing  tired,  weary,  worn  out  mothers. 
This  fact  is  coming  to  be  recognized  by  the  best  phy- 
sicians, and  as  a  result  more  attention  is  being  given 
to  the  mother  with  reference  to  her  ability  to  make 
good  milk.  She  is  taught  that  she  cannot  make  a 
quart  and  a  half  of  Jersey  milk  every  day  without 
something  to  make  it  of.  She  is  encouraged  to  take 
three  good  meals  a  day,  and  four  little  refreshments 
between.  These  come  the  first  thing  in  the  morning, 
the  middle  of  the  forenoon,  the  middle  of  the  after- 
noon, and  on  retiring.  She  is  taught  to  rest  abun- 
dantly, and  that  rested  milk  makes  baby  contented 
and  happy,  while  tired  milk  makes  baby  cross  and  ir- 
ritable,— therefore  she,  as  a  nursing  mother,  should 
seek  an  abundance  of  sleep.  She  lies  down  to  nurse 
her  baby,  lets  the  baby  lie  under  her  arm  and  not  on 
it,  gives  a  half  hour  to  each  nursing,  and  drops  to 
sleep  while  baby  nurses.     This  is  an  exceedingly  con- 


6  PRESENT    STATUS   OF    PEDIATRICS. 

servativ^e  habit  as  far  as  the  mother's  health  and 
beauty  are  concerned.  It  rests  the  organs  in  the 
pelvic  basket,  and  keeps  her  young,  rested,  and  light- 
hearted.  She  takes  her  daily  outing  in  the  fresh  air, 
in  the  sunshine  and  under  the  blue  sky.  She  culti- 
vates happy  moods  and  tenses,  remembering  always 
that  sweet  content  and  happy  thoughts  improve  the 
quality  of  the  milk,  while  depressions,  passions,  envy, 
jealousy,  suspicion,  hatred,  ill-will,  and  especially  ill- 
temper,  poison  baby's  milk. 

Sometimes  it  happens  that  the  mother  is  not  a 
"milker;  "  perhaps  she  comes  of  a  race  who  are  not 
good  nursers ;  perhaps  the  breasts  in  the  years  from 
sixteen  to  twenty  developed  under  the  pressure  of  the 
corset  and  so  made  an  imperfect  development ;  per- 
haps former  mammary  abscess  has  destroyed  the 
breast ;  perhaps  an  unwise  nurse,  by  neglect  or  inat- 
tention to  duty,  has  dissipated  it.  This  failure,  from 
whatever  cause,  necessitates  artificial  feeding,  and 
the  great  question  now  is — what  shall  we  feed  the 
baby. 

Artificial  Feeding. — Many  of  the  best  physicians 
regard  sterilized  milk,  properly  diluted,  as  the  most 
natural  of  all  foreign  foods,  while  a  very  large  class 
of  experienced  men  prefer  some  artificial  food,  such 
as  Mellin's  Food  or  Lacto-preparata.  No  one  food 
suits  every  stomach,  and  sometimes  we  have  to  feel 
our  way  till  we  find  one  that  suits.  In  artificial  feed- 
ing even  -greater  strictness  with  regard  to  keeping 
regular  hours  should  be  observed.  If  during  the  hot 
weather  of  summicr  or  during  fevers  baby  should  fret 
between  his  meal  times,  a  drink  of  pure  water  will 


THE    NEW-BORN    AND    INFANT    DIET.  7 

often  quiet  him.  Whatever  foods  are  given  should 
be  given  from  the  bottle  and  not  from  the  mug,  this 
is  a  slower,  neater,  and  easier  way  to  feed  the  baby, 
as  well  as  more  natural.  The  flat  cone  bottle  and 
the  black  or  red  Davidson  nipple  are  the  ones  most 
suited  to  the  purpose.  The  bottle  with  a  rubber  tube 
is  a  menace  to  baby's  life,  since  it  is  so  difficult  to 
keep  clean. 

So  to-day,  with  the  wise  physician,  much  attention 
is  given  to  those  conditions  and  habits  in  the  nursery 
which  prevent  rather  than  cure  disease.  To  eliminate 
the  terror  and  drudgery  of  motherhood  and  throw 
around  it  a  halo  of  loveliness  and  joy  should  be  the 
high  ambition  of  every  good  physician. 


PRESENT    STATUS    OF    PEDIATRICS, 


CHAPTER  II. 


DIATHETIC  DISEASES. 

BY   JOSEPH  P.   COBB,  M.  D.,  PROFESSOR  OF  PEDIATRICS,  HAHNEMANN 
MEDICAL   COLLEGE,   CHICAGO. 

RHACHITIS. — Rhachitis  is  a  disease  of  infancy  and 
early  childhood ;  its  mOst  marked  symptoms  appear 
between  the  sixth  month  and  the  second  year ;  it  may 
occur  at  any  age  and  is  occasionally  congenital;  it 
is  closely  associated  with  impaired  nutrition  and 
unhygienic  surroundings.  In  this  country  it  is  com- 
paratively rarely  observed  outside  of  large  cities, 
where  the  poor  and  destitute  are  crowded  together  in 
imperfectly  ventilated,  poorly  lighted,  and  filthily  kept 
tenements,  and  among  those  families  which  cannot  ob- 
tain suitable  food  or  which  do  not  appreciate  the  value 
of  proper  food  for  children.  Infants  nursed  by  a 
mother  who,  from  any  cause,  either  constitutional  or 
dietetic,  can  furnish  only  a  poor,  watery,  imperfectly 
organized  milk  may  become  rhachitic.  Such  mothers 
are  usually  anaemic  to  a  high  degree  and  their  milk 
when  examined  has  been  found  lacking  in  cream  and 
soluble  albumen  ;  it  contains  relatively  a  greater  pro- 
portion of  saline  ingredients  than  normal  milk,  but 
the  different  salts  do  not  appear  in  their  proper  rela- 


DIATHETIC    DISEASES — RHACKITIS.  9 

live  proportions ;  the  insoluble  albumin,  caseine,  ap- 
proaching nearest  to  its  normal  amount.  Though 
many  mothers  furnish  imperfect  milk,  the  majority 
of  nurslings  manage  to  escape  rhachitis  in  any  pro- 
nounced type  until  they  are  weaned;  where  the 
mother's  nutrition  is  poor  this  period  is  apt  to  occur 
early  in  their  infancy. 

Babies  fed  upon  artificially  prepared  food  from  the 
beginning  are  the  ones  who  are  more  prone  to  de- 
velop rhachitis  early,  and  yet  they  seldom  show  the 
marked  type  until  after  the  sixth  month.  Nature 
seems,  in  the  case  of  many  of  them,  to  be  able  to  make 
an  obstinate  fight  and  only  to  yield  when  persistently 
starved  out.  It  appears  to  be  a  matter  of  almost 
universal  agreement,  among  those  whose  opportuni- 
ties for  observation  among  these  classes  have  been  the 
most  extensive,  that  it  is  the  persistent  lack  of  fat — 
the  proper  kind  of  fat — and  the  lack  of  the  proper  sa- 
line ingredients  in  the  proper  proportions  in  the  in- 
fant's food,  which  at  least  makes  it  possible  for  the  dis- 
ease to  develop.  The  majority  of  the  manufactured 
foods  of  the  market,  and  especially  those  which  are 
intended  to  be  prepared  without  the  addition  of  fresh 
milk,  present  these  very  conditions ;  they  contain  far 
too  little  fat,  and  the  fat  that  is  present  is  not  animal 
fat ;  they  may  contain  an  excessive  proportion  of  saline 
matter  (which  in  itself  is  a  fault),  but  the  salts  have 
not  been  organized  by  animal  vitalities  and  materially 
differ  chemically  from  the  salts  of  the  milk.  Among 
the  better  classes,  where  unhygienic  surroundings  are 
not  a  prominent  etiological  factor,  the  food  of  the 
child  who  has  developed  rhachitis  is  almost  invariably 


lO  PRESENT    STATUS    OF    PEDIATRICS. 

found  to  have  been  one  of  the  fat  deficient  and  starch 
beridden  trade  compounds ;  a  compound  which  claims 
to  contain  all  of  the  nutritious  ingredients  of  milk  and 
various  cereals  in  an  easily  digestible  form  and  which 
the  manufacturer  asserts  is  a  "perfect  substitute  for 
mother's  milk."  This  observation  points  its  own 
moral,  viz. ,  that  the  proper  food  for  infants  is  milk.  It 
is  a  question  whether  unhygienic  surroundings  alone 
ever  produce  rhachitis.  Infants  and  children,  like 
young  plants,  cannot  thrive  without  sunshine;  and 
like  plants,  when  grown  in  an  atmosphere  vitiated  by 
poisonous  gases  and  deprived  of  sunshine,  become 
sickly,  stunted  specimens  of  their  kind.  These  influ- 
ences, how^ever,  though  potent  factors  in  developing 
rhachitis,  do  not,  in  the  absence  of  imperfect  foods, 
produce  typical  examples  of  the  disease. 

Anatomical  Changes. — The  deviation  from  the 
normal  standard  of  development  belonging  to  rhachi- 
tis may  be  observed  in  any  tissue.  It  is  true  that  it 
is  more  apparent  in  the  osseous  system,  and  for  this 
reason  the  bony  changes  have  received  more  atten- 
tion. The  changes  wrought  in  other  tissues  may, 
however,  be  even  more  serious  and  affect  the  child's 
expectancy  even  more  deeply  than  those  of  the  bones. 
Too  little  attention  has  been  given  to  the  deviation 
from  the  normal  standard  of  the  blood.  Anaemia  in 
some  form  is  usually  a  part  of  the  rhachitic  develop- 
ment, and  carries  with  it  its  pernicious  blood  compo- 
sition. The  number  of  red-blood  corpuscles  {erj- 
throcytes)  is  always  below  the  normal  proportion  and 
the  percentage  of  hceinoglobin  will  vary  in  the  same 
proportion.    The  white  corpuscles  {leucocytes)  are  also 


DIATHETIC    DISEASES — RHACHITIS.  II 

at  variance  with  the  normal  condition ;  they  may  be 
simply  deficient  in  number  or  deficient  in  develop- 
ment ;  in  pronounced  cases  they  are  abnormal  in  both 
of  these  respects.  While  these  observations  are  true 
in  varying  degrees  for  all  rhachitic  children,  in  the 
case  of  those  presenting  splenic  enlargements  it  be- 
comes a  more  pronounced  factor  for  evil.  In  such 
cases  the  number  of  erythrocytes  and  the  percentage 
of  hcEmoglobin  have  been  found  less  than  one-half  the 
normal  proportion,  while  more  than  three-fourths  of 
the  leneocytes  have  not  been  developed  up  to  a  good 
working  standard.  The  specific  gravity  of  the  blood 
is  below  normal  and  falls  in  direct  ratio  to  the  advance 
of  the  disease.  This  is  a  condition  of  the  disease,  it 
is  true,  but  it  is  a  pathological  difference  and  one  that 
affects  very  materially  the  ability  of  the  organism  to 
do  its  ordinary  work.  During  infancy  the  blood  of 
all  tissues  is  taxed  the  most  by  extra  demands  for 
growth  and  development,  and  to  its  inability  to  meet 
these  demands  may  be  ascribed  in  large  part  the  de- 
ficiencies of  other  tissues.  There  is  not  space  in  an 
article  of  this  character  to  dwell  in  extenso  upon  all 
of  the  varied  deformities  presented  by  a  typically  rha- 
chitic child.  In  reference  to  the  bony  changes  I  wish 
to  make  this  observation,  viz. ,  that  rarely  does  any 
one  child  present  all  of  the  possible  osseous  deformi- 
ties or  peculiarities.  The  rhachitic  rosary  is  often 
absent ;  so  are  any  marked  epiphyseal  enlargements. 
Craniotabes  are  only  present  in  extreme  cases,  but 
cranial  bossa  with  a  peculiar  cranial  contour  are  in 
some  degree  usually  present.  While  the  brachy- 
cephalic  cranium  with  its  flat  top  box-like  sides,  its 


12  PRESENT    STATUS    OF    PEDIATRICS, 

square  appearance  and  overhanging  forehead  is  the 
more  common  type,  we  should  remember  that  an- 
other type  with  an  exaggeratedly  long  antero-poste- 
rior  diameter  is  equally  as  characteristic.  In  this  class 
the  craniotabes  are  not  usually  to  be  observed,  but 
the  bossa,  fiat  top,  and  overhanging  forehead  are 
present.  Ossification  is  a  twofold  process  which  suf- 
fers in  rhachitis  in  both  particulars.  The  cartilagi- 
nous and  subperiostial  cell  growth  which  produces 
ossification  goes  on  with  increased  rapidity  and  in  an 
irregular  manner,  while  the  actual  ossification  is 
equally  irregular  or  even  wanting.  The  second  part 
of  the  process,  the  absorption  of  preliminary  forma- 
tions and  the  construction  of  medullary  and  other 
canals,  is  excessively  active.  There  is  a  deficiency  of 
building  material,  and  one  part  is  robbed  to  supply 
another. 

The  influence  upon  the  nervous  system  of  the 
rhachitic  anaemia  is  one  of  its  most  baneful  and  last- 
ing effects.  The  nervous  tissue,  like  the  osseous  tis- 
sue, does  not  receive  its  proper  building  material;  it 
is  starved,  and  consequently  is  improperly  devel- 
oped— the  nerve  centers  seem  to  suffer  the  most  se- 
verely, and  certain  ones  apparently  more  than  others. 
Rhachitic  children  are  often  precocious  in  their  men- 
tal development,  but  they  are  irritable,  easily  unbal- 
anced, and  more  prone  to  develop  some  form  of  nei;ve 
stome.  In  part,  we  should  ascribe  the  imperfect  tis- 
sue development  to  faulty  activity  of  the  trophic  cen- 
ters ;  next  to  these  nutritive  influences  I  should  place 
those  belonging  to  the  inhibitory  apparatus — the 
inhibition  of  reflexes  in  these  children  is  always  im- 


DIATHETIC    DISEASES — RHACHITIS.  13 

perfect,  they  do  not  learn  to  disregard  peripheral  im^ 
pulses  which  demand  no  consideration.  An  impulse 
which  should  give  rise  to  only  a  limited  reflex  re- 
sponse is  not  confined  to  its  simple  route,  but  is  trans- 
ferred to  other  centers  and  calls  out  unnecessarily 
complex  reflexes.  In  a  similar  way  volitional  inhibi- 
tion is  not  well  developed,  and  there  is  not  the  proper 
mental  control  even  in  those  whose  minds  are  preco- 
ciously active.  To  this  lack  of  inhibitory  control  and 
the  abnormal  irritability  of  nerve  terminations  is  due 
the  fact  that  these  children  are  prone  to  suffer  from 
partial  or  complete  convulsive  seizures.  Laryngismus 
stridulus  is  rarely  met  with  except  in  rhachitic  chil- 
dren, and  by  many  observers  is  claimed  as  a  diagnostic 
symptom  of  the  disease.  Convulsions,  which  may  oc- 
cur in  any  child  during  early  infancy,  are  liable  to 
follow  the  rhachitic  child  through  several  years  of  its 
early  life.  Convulsions  occurring  after  the  end  of  the 
first  year  should  always  excite  a  suspicion  of  this  dis- 
ease. 

Whenever  tetany  is  present  in  infancy  it  is  in  rha- 
chitic subjects.  Other  forms  of  nervous  irritability 
have  been  observed  in  these  children,  and  Erb  has 
pointed  out  the  fact  that  there  is  an  increased  electric 
excitability  of  nerves  to  both  f aradism  and  voltaism ; 
that  the  mode  of  reaction  to  the  voltaic  currents  is 
altered,  and  with  positive  and  negative  opening  there 
occurs  a  prolonged  contraction  or  tetanus.  The  mus- 
cular system  is  never  as  well  developed ;  its  tissue 
does  not  present  the  normal  tonicity,  it  has  not  the 
same  power  of  performing  work,  and  it  cannot  as 
readily  recuperate  after  exhaustion  of  its  excitability. 


14  PRESENT    STATUS    OF    PEDIATRICS. 

The  glandular  apparatus  suffers  both  in  its  structu- 
ral and  functional  developments;  individual  glands 
may  be  abnormally  large,  and  this  is  often  the  case 
with  the  liver,  spleen,  and  pancreas ;  this  enlargement 
is  due,  however,  to  increase  of  connective  tissue,  with 
a  corresponding  diminution  of  active  cell  structure ; 
the  capability  of  the  gland  is  usually  in  reverse  ratios 
to  its  abnormal  developments,  Nonassimilation  is 
always  a  factor  of  rhachitis,  and  in  the  shape  of 
chronic  catarrhal  gastro-enteritis  and  persistent  dys- 
peptic diarrhoea  may  be  its  herald,  or  at  least  its  first 
manifestation.  When  the  disease  is  well  advanced 
we  could  hardly  expect  anything  else.  Its  low  stand- 
ard of  blood  structure,  inefficiency  of  nervous  con- 
trol, with  consequent  proneness  to  venous  stases,  its 
tendency  to  excessive  mucous  secretions,  and  its  im- 
paired organs  and  tissues  offer  all  of  the  conditions 
possible  for  impaired  food  metabolism  and  assimila- 
tion. 

Relation  to  Other  Diseases. — While  I  do  not 
agree  with  Parrot  that  rhachitis  is  always  an  outcome 
of  syphilis  in  a  preceding  generation,  my  observation 
has  taught  me  that  the  disease  is  frequently  developed 
from  syphilitic  parentage.  The  impairment  of  the 
mother's  nutrition  by  syphilis  seems  to  offer  exceed- 
ingly good  ground  into  which  to  engraft  rhachitis ; 
moreover,  both  diseases  are  frequently  found  co-ex- 
isting in  infants.  Children  in  whom  tubercular  con- 
ditions are  either  active  or  latent  seem  to  have  an 
immunity  from  rhachitis. 

Rhachitic  children  are  always  catarrhal  subjects; 
they  develop  acute  catarrhs  under  slight  provoca- 


DIATHETIC    DISEASES^ — RHACHITIS.  15 

tions;  catarrhal  inflammation  in  them  are  liable  to 
affect  submucous  tissues  and  be  destructive  in  their 
course  and  results,  and  have  a  predilection  to  become 
chronic. 

In  the  vegetative  part  of  the  system  I  find  the  pri- 
mary causes  of  the  development  of  this  disease ;  and 
I  am  also  sure  in  my  own  mind  that  in  the  vegeta- 
tive system,  and  in  the  character  of  its  works,  we 
shall  find  its  first  manifestations.  For  this  reason, 
except  in  very  advanced  cases,  the  prognosis,  so  far  as 
life  is  concerned,  is  usually  favorable.  The  disease 
may  be  arrested  in  any  of  its  stages,  and  many  vitiated 
tissues  and  organs  may  be  brought  up  to  a  healthy 
standard  ;  bony  excrescences  may  be  wholly  or  in  part 
reabsorbed,  crooked  bones  may  be  improved  by  the 
improvement  of  muscular  tone ;  i'mproved  nutrition 
may  make  it  possible  for  the  surgeon  to  work  won- 
ders with  a  deformed  skeleton;  abnormally  large 
glands  with  little  physiological  capability  may  be 
brought  to  a  fair  degree  of  usefulness ;  and  an  equi- 
poise of  the  nervous  system,  necessary  for  the  main- 
tenance of  health,  may  be  acquired. 

The  ^^  sine  qua  non"  for  these  changes  are  good 
food  and  hygienic  surroundings. 

I  do  not  in  this  statement  wish  to  despise  or  under- 
rate the  value  of  medication.  I  believe  that  our  knowl- 
edge of  such  remedies  as  the  calcarea  compounds, 
phosphorus  Q-ndi  t\iQ  phosphates,  iodiiun  Q.n&  the  iodides, 
and  others,  often  as  serviceable,  makes  it  possible  for 
us  to  obtain  results  out  of  the  reach  of  our  allopathic 
friends  both  as  regards  time  and  extent.  Yet  our 
remedies  will  accomplish  little  if  our  patient  is  not 


l6  PRESENT    STATUS    OF    PEDIATRICS. 

fed  properly  and  has  not  the  chance  to  make  the  ac- 
quaintance with  sunshine. 

RHEUMATISM.— The  delicate  tissues  and  organi- 
zation of  children  exhibit  a  more  extensive  area  of 
disturbances  under  the  influence  of  rheumatism  than 
is  found  in  those  of  the  adult.  Rheumatism  was 
formerly  supposed  to  rarely  occur  in  children  and 
never  in  infants,  but  more  careful  observations  show 
that  it  is  as  common  in  children  as  in  adults,  and  that 
it  is  not  uncommon  during  early  infancy.  In  chil- 
dren the  phenomena  are  not  limited  to  the  fibrous 
tissues,  the  synovial  and  serous  membranes.  Ery- 
thema, tonsillitis,  chorea,  pleurisy,  tendinous  nodules 
are  just  as  frequent  manifestations  of  rheumatism  in 
children  as  arthritis  and  pericarditis  are  in  adults; 
while  endocarditis,  usually  considered  in  adults  as  a 
sequela  of  the  disease,  is  in  childhood  a  frequent  and 
at  times  the  only  phenomenon  observed.  The  vari- 
ous manifestations  of  rheumatism  are  in  adults  apt 
to  be  massed  together  and  appear  within  a  few 
weeks;  in  children,  on  the  other  hand,  they  show  a 
tendency  to  be  distributed  over  years,  and  may  be 
the  history  of  a  whole  childhood.  Arthritis,  the 
most  characteristic  feature  of  the  disease  in  adult 
life,  is  in  children  the  least  prominent,  while  endo- 
carditis, one  of  the  rarer  phenomena  in  adults,  is  one 
of  the  most  frequent  and  persistent  types  in  children. 

Etiology. — The  most  certain  predisposing  factor 
of  rheumatism  in  childhood  is  hereditary  influence. 
The  most  common  exciting  cause  is  chilling  of  the 
surface  of  the  body.  The  poison  of  scarlatina  seems 
also  to  be  a  direct  exciting  cause. 


DIATHETIC    DISEASES RHEUMATISM.  I  7 

'14ie  exact  essential  etiological  factor  of  the  disease 
has  not  been  demonstrated.  The  most  commonly 
accepted  theory,  that  it  is  due  to  irritation  from  the 
excessive  amount  of  lactic  acid  present  in  the  system, 
is  not  admitted  as  proven.  It  is  the  old  question  of 
'■^ post  hoc''  and  ^^ propter  hoc/'' 

Dr.  J,  R.  Mitchell's  theory  of  its  neurotic  origin 
has  to-day  no  common  acceptance. 

Dr.  T.  J.  Maclagan,  in  the  "Twentieth  Century 
Practice  of  Medicine, "  makes  a  strong  plea  for  the 
miasmatic  theory  of  rheumatism. 

Dr.  Alfred  Mantle  claims  to  have  found  a  micro- 
coccus and  a  small  bacillus  constantly  present  in 
rheumatic  lesions.  He  has  made  cultures  of  these 
micro-organisms  and  reports  successful  inoculations. 
His  experiments  have  been  verified  by  very  few  and 
are  disputed  by  others.  The  fact  that  endocarditis 
has  been  shown  to  be  of  microbic  origin  lends  force 
to  this  theory. 

In  the  face  of  all  of  these  conflicting  theories  we 
have  as  universally  accepted  facts  only  the  clinical 
features  of  inheritance  and  chilling  of  the  surface. 

Clinical  History. — Acute  rheumatism  may  pre- 
sent itself  in  a  variety  of  forms,  depending  upon  the 
organ  or  tissue  most  seriously  involved.  It  can  be 
more  concisely  discussed  by  describing  individually 
its  various  types.  It  should  be  borne  in  mind  that, 
especially  after  the  sixth  year  of  life,  rheumatism 
may  present  itself  in  the  classical  way  and  run  an 
ordinary  course.  In  such  cases  the  onset  is  sudden, 
the  maximum  of  the  disease  is  reached  in  a  short 
time  (two  or  three  days),  the  temperature  does  not 


l8  PRESENT    STATUS    OF    PEDIATRICS. 

range  high  (102  to  103  F. ),  the  course  of  the  disease 
is  short  (two  to  three  weeks),  new  attacks,  or  scquelcB^ 
are  apt  to  appear  in  succeeding  years. 

Arthritis. — As  has  been  already  mentioned,  ar- 
thritis is  neither  a  common  nor  a  severe  symptom  of 
rheumatism  in  children.  It  is  frequently  present 
only  as  a  little  stiffness  or  tenderness  of  one  or  two 
joints,  with  but  slight  febrile  reaction.  Its  signifi- 
cance is  often  entirely  overlooked,  until  endocarditis 
or  some  other  symptom  develops  and  recalls  its  oc- 
currence ;  so  frequently  is  it  the  case  that  no  history 
of  arthritis  is  obtained,  that  all  writers  state  that  it 
is  not  necessarily  a  part  of  the  disease.  In  other 
cases  the  inflammation  may  be  limited  to  the  tendon 
or  sheath  of  a  muscle,  and  give  rise  to  a  muscular 
contracture  as  the  only  primary  symptom  of  the  dis- 
ease. Torticollis  is  a  frequent  manifestation  of  this 
type.  Next  in  frequency,  and  often  misleading,  is  a 
localization  of  the  inflammation  in  the  ham-string 
tendons  at  the  back  of  the  knee,  causing  an  inability 
of  the  child  to  put  the  heel  to  the  ground  in  walking. 
Profuse  acid  perspiration  and  its  attendant  results, 
sudamina  and  miliaria,  are  not,  as  in  adults,  common 
symptoms  of  acute  arthritis.  While  the  inflamma- 
tion may,  as  it  is  prone  to  do  in  adults,  involve 
many  joints,  it  is  more  liable  to  be  limited  to  one 
or  two.  Persistent  joint  inflammation  or  even  ten- 
derness should  always  suggest  to  our  minds  tubercu- 
losis. 

Endocarditis. — In  the  majority  of  all  cases  endo- 
carditis appears  either  w4th  or  following  the  joint  dis- 
ease.    Very  often  it  appears  at  the  time  as  the  sole 


DIATHETIC    DISEASES — RHEUMATISM.  jg 

evidence  of  the  disease,  or  it  may  be  associated  with 
the  development  of  subcutaneous  nodules,  an  index  of 
valvular  involvement.  Again,  erythema  or  chorea 
may  be  the  accompanying  conditions.  In  all  of 
these  types  the  endocarditis  develops  slowly  and  in- 
sidiously ;  does  not  for  some  time  attract  any  atten- 
tion ;  is  prone  to  continue  and  to  relapse.  The  in- 
flammation has  a  special  tendency  to  attack  the 
valves,  particularly  the  mitral  valve,  and  to  produce 
serious  lesions.  The  valves,  the  fibrous  tendons  of 
the  valves,  or  the  musculo-fibrous  ring  around  the 
opening  may  be  thickened,  distorted,  or  contracted 
by  inflammatory  deposits.  Fibrous  nodules  on  the 
valves  and  tendons  are  frequently  found  at  post- 
inorteni  examinations.  Fibrinous  masses  may  be 
washed  from  the  sites  of  inflammation  and  cerebral 
or  pulmonary  embolism  result.  These  pronounced 
lesions,  with  their  signs,  do  not  appear  early.  Rest- 
lessness, anxiety,  hurried  breathing,  pain  in  the  car- 
diac region,  and  slight  fever  are  the  early  symptoms. 
As  the  disease  progresses,  a  mitral  or  more  rarely  an 
aortic  murmur  is  developed  (a  diastolic  mitral  or 
aortic  murmur  is  not  often  found),  the  impulse  be- 
comes increased  in  force,  the  pulse  becomes  more  fre- 
quent and  irregular  in  force.  The  rise  in  tempera- 
ture even  in  severe  forms  of  endocarditis  may  not  be 
more  than  one  or  two  degrees. 

Pericarditis. — Like  endocarditis,  it  may  appear 
with  or  before  any  joint  affection ;  it  is  not  as  frequent 
in  young  children  as  endocarditis ;  in  older  children 
it  is  frequently  associated  with  it ;  it  has  the  same 
tendency  to  become  subacute,  chronic,  and  intermit- 


20  PRESENT    STATUS    OF    PEDIATRICS. 

tent ;  otherwise  it  does  not  differ  from  the  same  con- 
dition in  adults,  and  presents  the  same  signs. 

Pleurisy  and  Pneumonia. — These  are  much  less 
frequent  than  cardiac  lesions.  •  Pneumonia  only  oc- 
curs as  an  accompaniment  of  pleurisy,  pericarditis  or 
mitral  disease,  or  as  the  result  of  an  embolism ;  in 
any  case  it  will  be  left-sided.  Pleurisy  may  occur  as 
a  primary  expression  of  rheumatism,  or  it  may  be 
secondary  to  pericarditis.  In  the  former  case  it  is 
readily  amenable  to  treatment,  in  the  latter  it  adds  a  se- 
rious complication  to  an  already  dangerous  condition. 

Tonsillitis. — An  inflammation  of  the  tonsils  and 
pharynx,  v/ith  fever  and  difficulty  in  swallowing,  may 
usher  in  an  attack  of  acute  rheumatism,  may  accom- 
pany any  form  of  primary  manifestation  or  may  oc- 
cur at  any  stage  of  the  disease.  Rheumatic  children 
are  always  prone  to  attacks  of  tonsillitis. 

Erythema. — Erythema  is  frequently  present  with 
either  articular  or  cardiac  forms  of  the  disease ;  or  it 
may  appear  during  the  quiescence  of  other  symptoms 
and  represent  a  separate  stage.  ErytJicnia  niargina- 
tiun  and  urticaria  are  the  more  common  forms.  E?'y- 
thema  nodos2iin  and  purpuric  erythema  are  also 
claimed  as  evidences  of  the  disease. 

Fibrous  Nodules. — Subcutaneous  nodules  are  as 
common  in  children  as  they  are  rare  in  adults.  They 
vary  in  size  from  that  of  a  pin's  head  to  that  of  an 
almond ;  they  are  hard,  slightly  sensitive  to  pressure, 
and  are  apt  to  appear  in  the  neighborhood  of  a  joint; 
they  tend  to  come  and  go,  and  are  almost  invariably 
a  sign  of  cardiac  affection.  Recurring  crops  indicate 
a  progressive  cardiac  lesion. 


DIATHETIC    DISEASES RHEUMATISM.  21 

Chorea. — Not  all  cases  of  chorea  are  due  to  rheu- 
matism, but  a  large  proportion  of  cases  are  associated 
with  the  rheumatic  state ;  this  is  particularly  true  of 
those  cases  appearing  between  the  years  of  ten  and 
fifteen.  It  occurs  in  connection  with  simple  joint 
pains,  which  are  probably  rheumatic ;  it  frequently  at- 
tends or  follows  distinctly  rheumatic  arthritis ;  it  oc- 
curs in  connection  with  endocarditis  and  pericarditis ; 
it  bears  no  relationship  to  any  other  disease  except 
scarlatina,  which  also  has  an  etiological  connection 
with  rheumatism.  When  associated  with  rheuma- 
tism it  is  more  intractable  than  when  not  so  associ- 
ated. 

Anaemia  is  a  prominent  symptom  of  rheumatism 
in  children.  To  a  certain  extent  it  is  present  in  all 
cases,  and  sometimes  progresses  to  an  extreme  de- 
gree. It  may  be  accountable  in  part  for  the  serious 
lesions  in  cardiac  manifestations.  The  most  serious 
part  of  rheumatism  is  the  extent  of  the  lesions 
which  may  be  produced  by  the  cardiac  inflammation. 
The  acute  attacks  are  apt  to  run  a  mild  and  rapid 
course,  early  convalescence  is  to  be  expected,  but 
cardiac  lesions  are  of  frequent  occurrence,  are  in- 
sidious in  their  development,  and  are  intermittently 
persistent  if  left  to  themselves.  Serious  cardiac 
lesions  may,  however,  with  help  be  wonderfully  re- 
paired if  relapses  can  be  prevented. 

Treatment. — The  most  important  point  to  bear  in 
mind  in  the  treatment  of  this  disease  in  children  is  the 
liability  to  relapses  and  sequela;.  Proper  clothing, 
hygienic  surroundings,  a  climate  devoid  of  sudden 
changes,  a  locality  free  from  miasmatic   influences, 


2  2  PRESENT    STATUS    OF    PEDIATRICS. 

and  a  persistent  attention  to  general  health  are  all 
greatly  to  be  desired;  unfortunately  the  rheumatic 
child  frequently  cannot  command  all,  or  even  any  of 
these  conditions.  Rest  of  the  affected  part  and  gen- 
eral rest  should  be  maintained ;  during  an  acute  mani- 
festation the  child  should  remain  in  bed.  The  reme- 
dies to  be  employed  do  not  materially  differ  from  those 
which  have  proven  themselves  useful  in  the  disease 
as  observed  in  adults. 

Aconite  and  bryonia  I  have  not  found  as  frequently 
indicated,  probably  because  the  arthritic  form  of  the 
disease  is  not  as  common  or  pronounced. 

Ferruni  pJiospJioriciun  is  often  useful  for  anaemic 
children  where  there  is  great  sensitiveness  of  the  skin, 
general  irritabilty,  moderate  fever,  and  indefinite 
pains.  In  the  early  stages  of  endocarditis  it  has 
been  of  great  service  to  me. 

ActiJ^  ract'jnosa,  or  its  alkaloid,  inacrotiii,  is  of  espe- 
cial value  for  the  pronounced  cardiac  lesions,  fibrous 
nodules,  and  muscular  contractures  due  to  inflamma- 
tion of  tendons  and  muscle  sheaths. 

Kalniia  latifolia  enjoys  a  reputation  for  its  ability 
to  control  endocarditis  and  pericarditis  in  rheumatic 
subjects,  but  my  observation  does  not  bear  this  out  in 
the  case  of  children.  JMacrotin  and  fcrriim  phos- 
phor ten  ?n  have  been  of  more  service  to  me. 

Rhus  toxicodendron  frequently  finds  its  counterpart 
in  the  condition  of  rheumatic  children.  Great  rest- 
lessness, severe  pain,  muscular  soreness,  and  an  ap- 
proach to  a  typhoid  picture  will  always  suggest  its  use. 

Phytolacca^  more  frequently  than  any  other  remedy, 
will  be  indicated  for  the  throat  affections. 


DIATHETIC    DISEASES SYPHILIS.  23 

Pulsatilla — The  erratic  rheumatoid  pains  from 
slight  chilling,  general  hyperaesthesia,  morbid  sensi- 
tivness,  aggravated  from  dietary  excesses  (candy, 
etc.),  choreic  manifestations  are  all  classic  symptoms 
of  Pulsatilla. 

Sulphur  is  a  remedy  too  frequently  neglected  in 
rheumatism.  There  is  hardly  a  rheumatic  child  that 
does  not  at  some  stage  of  the  disease  require  sulphur. 
There  is  no  remedy  which  will  so  frequently  help  us 
in  preventing  the  relapses,  the  returns,  and  the  new 
phases  of  this  disease. 

SYPHILIS. — Syphilis  in  infancy  and  childhood  may 
be  either  acquired  or  hereditary. 

Acquired  syphilis  in  infancy  and  childhood  is 
contracted  in  the  same  way  as  in  adults,  viz. ,  by  the 
inoculation  with  virus  from  a  chancre  or  bubo,  or  from 
certain  secondary  lesions.  The  secondary  lesions  now 
universally  admitted  as  capable  of  causing  infection 
are  mucous  patches,  and  cutaneous  lesions  having  an 
exudation.  Fissures  and  cracks  at  the  muco-cutane- 
ous  margins,  excoriated  nipples,  mucous  patches  or 
tubercles  on  the  tongue,  or  the  saliva  of  one  who  has 
any  syphilitic  lesion  of  the  mouth,  pharynx,  or  nasal 
fossa  are  capable  of  giving  the  infection.  In  all  cases 
there  will  be  at  the  site  of  infection  the  usual 
chancre,  and  the  usual  after  effects  of  the  disease  will 
follow.  There  is  nothing  especially  different  in  the 
course  of  the  disease  in  childhood ;  its  varied  mani- 
festations will  not  be  considered  in  this  discussion. 
It  is  worth  while,  however,  to  mention  the  fact  that  a 
child  may  be  infected  at  birth  by  its  mother,  or  shortly 
after  birth  by  someone  else,  the  primary  chancre  be 


24 


PRESENT    STATUS    OF    PEDIATRICS 


overlooked,  and  the  secondary  symptoms  be  mistaken 
for  the  hereditary  form. 

Hereditary  Syphilis. — Either  parent  having  syph- 
iHs  in  its  first  or  second  stage  may  transmit  the  dis- 
ease to  their  offspring,  even  though  at  the  time  of 
conception  neither  parent  shows  any  symptoms  of 
the  disease.  If  both  parents  have  syphiHs  at  the 
time  of  conception,  the  disease  is  invariably  trans- 
mitted to  the  child,  and  usually  in  a  virulent  form. 
If  only  one  parent  is  syphilitic,  the  child  may  or  may 
not  be  syphilitic.  If  the  mother,  healthy  at  the  time 
of  conception,  contracts  syphilis  prior  to  the  eighth 
month  of  pregnancy,  she  may  transmit  the  disease  to 
the  child  in  ittero.  Syphilis  contracted  by  the  mother 
during  the  eighth  or  ninth  month  of  pregnancy  is  not 
likely  to  be  transmitted  to  the  child,  but  unless  es- 
pecial care  is  used  the  infant  is  liable  to  be  infected 
at  birth.  It  is  universally  agreed  by  all  observers 
that  syphilis,  after  the  close  of  the  second  stage,  is 
not  transmitted  to  the  offspring,  but  such  parents  are 
liable  to  beget  children  who  will  be  especially  prone 
to  develop  rhachitis,  and  be  especially  liable  to  tuber- 
cular and  catarrhal  inflamations.  The  chances  of  in- 
fection of  the  foetus  and  the  severity  of  the  type,  if 
infected,  are  in  direct  proportion  to  the  activity  of 
the  disease  in  the  parents.  Specific  treatment  lessens 
the  liability  to  infection.  Continuous  treatment  for 
eighteen  to  twenty-four  months  is  believed  to  eradi- 
cate the  possibility  of  hereditary  transmission.  Time 
alone  has  its  influence  in  this  direction.  Four  years 
in  the  father  and  six  years  in  the  mother  are  consid- 
ered a  sufficient  time  tor  the  specmc  nereditary  mnu- 


DIATHETIC    DISEASES — SYPHI-LIS.  25 

ences  to  run  out.  Children  begotten  during  the  period 
of  primary  activity  are  liable  to  be  still-born  or  to  die 
soon  after  birth.  If  a  father  infects  the  mother, 
the  child  is  almost  sure  to  be  still-born  or  to  die 
soon  after  birth.  During  periods  of  latency  of  the 
disease  the  mother  may  bear  healthy  children  and 
give  birth  later  to  syphilitic  children  as  a  result  of 
renewed  activity  on  the  part  of  the  disease  within 
herself.  Children  conceived  some  time  (two,  three, 
or  four  years)  after  the  infection  of  the  parent  or 
parents  are  not  liable  to  develop  virulent  forms  of  the 
disease ;  are  not  liable  to  manifest  the  symptoms  early ; 
are  not  liable  to  show  the  ordinary  symptoms  of  he- 
reditary syphilis;  they  are  more  liable  to  develop  the 
symptoms  corresponding  to  the  late  manifestations  of 
the  acquired  disease,  such  as  periostitis  and  affections 
of  the  nervous  system. 

Syphilitic  Virus. — Most  pathologists  believe  that 
syphilis  is  a  microbic  disease,  but  it  has  not  been  de- 
termined what  special  micro-organism  is  the  essential 
factor  in  the  disease.  The  bacillus  discovered  by  Lust- 
garten  to  be  present  in  syphilitic  lesions  is  the  only 
one  which  has  established  any  claim  to  recognition. 
The  inability  thus  far  to  cultivate  this  organism,  and 
the  fact  that  no  animal  except  man  is  capable  of  in- 
oculation, has  as  yet  rendered  a  proof  of  its  etiolog- 
ical importance  impossible.  It  has  not  even  been 
agreed  whether  the  bacillus  itself  or  only  its  toxines 
migrate  from  the  parent  to  the  offspring. 

Pathology. — The  more  common  form  of  tissue 
change  which  takes  place  in  hereditary  syphilis  is 
diffuse  interstitial  h3^perplasia  of  the  connective  tissue ; 


26  PRESENT    STATUS    OF    PEDIATRICS. 

circumscribed  g-ummata  are  much  less  common  than 
in  the  acquired  form.  The  visceral  organs  liable  to 
be  affected  and  in  their  ratio  of  frequency  are  the 
spleen,  pancreas,  liver,  lungs,  testicles,  and  kidneys. 
In  the  case  of  each  organ,  as  above  stated,  the  lesion 
is  usually  an  interstitial  hyperplasia  of  connective  tis- 
sue, which  increases  the  size  and  density  of  either 
the  whole  or  some  part  of  the  organ,  and  which  en- 
croaches upon  the  essential  cell  structure,  thus  im- 
pairing its  physiological  capabilities.  These  lesions, 
when  not  too  severe,  are  often  amenable  to  treatment. 
The  bone  lesions  are  of  two  types,  viz.,  osteochon- 
dritis and  osteoperiostitis.  Both  lesions  are  more 
liable  to  involve  the  long  bones.  Osteochondritis 
belongs  to  early  infantile  manifestations,  while  osteo- 
periostitis is  usually  observed  later  on  toward  the 
period  of  puberty.  Osteochondritis  is  peculiar  to 
syphilis,  and  starts  at  the  zone  of  proliferation  be- 
tween the  bone  and  epiphyseal  cartilage.  It  may 
materially  affect  the  growth  of  the  bone.  It  is  apt 
to  be  symmetrical.  The  number  of  bones  involved 
appears  to  be  in  direct  ratio  to  the  virulence  of 
infection,  and  the  greater  the  number  of  bones  in- 
volved the  graver  are  the  infant's  prospects  of  life. 
Besides  these  common  types,  dactylitis  frequently  oc- 
curs, and  the  fingers  or  toes  may  swell  to  twice  their 
normal  size,  assuming  a  peculiar  pyriform  shape. 
Upon  the  skin  we  may  have  lesions  of  the  type  of 
erythema,  macules,  papules,  vesicles,  and  pustules. 
It  is  quite  characteristic  of  syphilis  to  have  a  variety 
of  skin  lesions  co-existing;  blebs  appearing  either  at 
birth  or  in  the  first  months  of  infancy  upon  the  palms 


DIATHETIC    DISEASES — SYPHILIS. 


27 


of  the  hands  or  soles  of  the  feet  are  also  character- 
istic. Catarrhal  inflammations  of  some  part  of  the 
mucous  membrane  of  either  the  respiratory  or  ali- 
mentary tract,  or  both,  are  present,  mucous  patches 
may  be  found  in  the  mouth  or  pharynx,  and  fissures 
at  some  of  the  muco-cutaneous  margins. 

Clinical  History. — Under  the  influence  of  the 
syphilitic  poison  the  foetus  often  ceases  to  grow,  dies, 
and  is  expelled  long  before  term.  It  may  be  born 
prematurely,  and  show  marked  indications  of  the  dis- 
ease when  it  comes  into  the  world,  or  it  may  be  born 
at  term  but  dead.  About  seventy  per  cent  of  still 
births  are  due  to  syphilis ;  in  such  cases  the  foetus  is 
usually  macerated  and  may  show  bullae.  The  clinical 
course  of  the  disease  presents  itself  in  two  rather  pro- 
nounced types,  the  early,  occurring  in  infancy,  and 
the  late  type  toward  puberty. 

The  Early  Manifestations. — The  early  symptoms, 
correspond  to  the  secondary  stage  of  acquired  syph- 
ilis. In  the  severe  types  the  infant  shows  at  birth, 
or  within  a  few  weeks  after  birth,  an  efflorescence  of 
the  skin ;  this  efflorescence  has  a  predilection  for  the 
nates,  the  parts  around  the  genitalia,  the  palms,  and 
the  soles.  A  simple  erythema  represents  a  mild 
form  of  the  disease,  while  papules  and  pustules  each 
indicate  a  severer  type  of  infection.  Blebs  are  found 
in  pronounced  cases,  and  when  occurring  on  the 
palms  and  soles  are  very  characteristic.  Together 
with  the  efflorescence  there  is  present,  or  early  de- 
velops, a  persistent  excoriating  coryza ;  complete  oc- 
clusion of  the  nares  may  occur.  The  cry  is  hoarse, 
weak,    and    often   only  a   plaintive   whimper.      The 


28  PRESENT    STATUS    OF    PEDIATRICS. 

child  is  small,  poorly  developed ;  there  is  an  absence 
of  any  subcutaneous  fat ;  the  skin  is  dry  and  hangs 
in  fold;  the  face  has  an  old,  anxious  expression. 
Syphilitic  infants  rarely  look  happy,  never  smile,  and 
are  very  fretful ;  persistent  fretfulness  and  crying  at 
night  are  in  themselves  always  suggestive  of  heredi- 
tary syphilis.  These  children  always  manifest  evi- 
dences of  indigestion.  Dyspeptic  diarrhoea,  with  foul 
smelling  excreta  containing  mucus  and  undigested 
food,  is  the  usual  accompaniment  of  the  disease.  All 
of  the  excreta,  including  the  perspiration  and  breath, 
are  foul  smelling,  and  a  peculiar  penetrating  odor 
clings  to  the  child  even  after  its  bath.  These  digest- 
ive symptoms  are  in  part  due  to  catarrhal  inflamma- 
tions of  the  stomach  and  intestine  and  in  part  to  the 
lesions  of  the  digestive  glands,  the  liver,  spleen,  and 
pancreas. 

Syphilitic  lesions  of  the  mouth  in  early  infancy 
consist  of  mucous  ulcerations  on  the  cheeks,  tongue, 
and  lips ;  they  are  more  or  less  painful  and  sluggish 
in  repair.  Those  involving  the  lips  are  apt  to  select 
the  commissures  of  the  mouth  and  produce  deep 
fissures  with  indurated  bases;  these  are  known  as 
rhagades.  As  a  result  in  part  of  the  impaired  diges- 
tion, we  may  have  various  forms  of  stomatitis  en- 
grafted upon  these  mucous  sores  which  do  not  repre- 
sent purely  syphilitic  lesions.  These  children  usu- 
ally show  osteochondritis  of  some  of  the  long  bones ; 
so  common  is  this  the  case  that  some  authors  claim 
that  the  diagnosis  of  this  early  type  is  not  made  until 
it  is  found.  Children  are  frequently  born  apparently 
healthy,  showing  no  evidence  of  impaired  nutrition 


DIATHETIC    DISEASES — SYPHILIS.  29 

or  Other  lesions  until  some  months  after  birth,  when 
characteristic  syphilitic  lesions  make  their  appear- 
ance. It  is  claimed  that  the  virus  may  remain  latent 
until  the  sixth  month,  but  certainly  in  the  great  ma- 
jority of  cases  they  develop  before  the  close  of  the 
third  month  of  infancy.  The  symptoms  do  not  differ 
from  those  which  we  have  described  as  appearing  im- 
mediately after  birth,  and  may  go  on  to  the  same 
fearful  extent.  As  a  general  rule,  the  later  the  symp- 
toms begin  to  appear  and  the  slow^er  they  develop, 
the  more  amenable  to  treatment  and  the  less  severe. 

All  of  these  cases  do  not  show  the  typical  lesions 
of  the  disease,  and  in  mild  cases  there  may  be  a 
doubt  as  to  their  character.  A  persistent  acrid  coryza, 
even  without  mucous  ulceration,  persistent  dyspeptic 
foul  smelling  diarrhoea  with  emaciation,  an  old  ex- 
pression with  wrinkled  anxious  face,  persistent  fret- 
fulness  with  insomnia,  are  all  classical  symptoms. 
If  any  of  these  conditions  are  present,  together  with 
an  enlarged  liver  and  spleen,  there  can  be  little  doubt 
of  their  significance.  When  osteochondritis  is  found, 
all  doubts  are  removed. 

A  large  proportion  of  syphilitic  children  die,  but 
many  who  present  very  grave  lesions  and  who  de- 
velop the  lesions  early  in  infancy  do  not  succumb  to 
the  disease.  The  most  important  point  in  their  care 
is  to  maintain  their  general  nutrition.  This  is  not 
always  easy  to  do.  The  mother  often  does  not  have 
sufficient  breast  milk,  and  when  the  mother  herself 
has  been  suffering  from  the  disease  her  milk  is  very 
frequently  an  insufficient  food.  Syphilitic  babies 
should  not  be  given  to  a  wet-nurse,  because  of  the 


3©  PRESENT    STATUS   OF    PEDIATRICS. 

danger  to  the  nurse.  Their  food  is  often  prepared 
with  no  appreciation  either  of  their  wants  or  of  their 
feeble  digestive  powers.  The  more  an  infant's  di- 
gestion is  impaired  the  harder  it  becomes  for  him  to 
digest  caseine.  Fat  and  sugar  are  what  they  need, 
and  cream  and  sugar  of  milk  are  what  they  can 
digest  with  the  least  effort.  I  have  found  a  simple 
cream  mixture  which  does  not  contain  more  than 
one  per  cent  of  caseine,  four  per  cent  of  fat,  and 
seven  per  cent  of  sugar  of  milk  the  best  food  for 
them  and  the  most  likely  to  be  well  digested.  Where 
a  milk  laboratory  can  be  called  upon  for  aid,  there  is 
no  trouble  in  obtaining  the  desired  proportions. 
Where  fresh  cow's  milk  can  be  obtained,  we  can 
make  a  good  substitute  milk.  Good  cream  contains 
from  sixteen  to  twenty  per  cent  of  fat  and  one  to 
four  per  cent  of  proteids;  diluted  with  five  or  six 
parts  of  water  to  one  part  of  cream  it  will  give  a 
fair  proportion  of  fat ;  sugar  of  milk  should  be  added 
in  the  proportion  of  3^8  drachms  to  every  eight 
ounces  of  the  mixture. 

Much  discussion  has  taken  place  as  to  the  relation- 
ship between  rhachitis  and  syphilis  and  between  tu- 
berculosis and  syphilis.  Rhachitis  is  essentially  a 
disease  of  malnutrition,  and  anything  which  so  pro- 
foundly affects  the  nutrition  as  syphilis  can  undoubt- 
edly influence  its  development.  The  characteristic 
bone  lesions  are  entirely  different,  and  it  is  not  an 
unusual  thing  to  find  both  lesions  existing  in  the  same 
case.  A  syphilitic  parentage,  where  the  active  evi- 
dences of  the  disease  have  been  overcome,  may  trans- 
mit a  weakened  constitution  which  less  easily  with- 


DIATHETIC    DISEASES — SYPHILIS.  3  I 

stands  the  deprivation  and  unhygienic  surroundings 
which  are  the  progenitors  of  rhachitis.  Tuberculosis, 
Hke  vSyphilis,  is  a  disease  of  civilization,  and  some  re- 
searches which  have  of  late  been  made  seem  to  show 
that  tuberculosis  follows  syphilis;  that  not  until 
syphilis  has  lowered  the  natural  resiliency  of  a  race 
are  they  liable  to  tuberculosis.  In  the  individual 
case  we  know  that  an  organism  which  has  suffered 
the  ravages  of  syphilis,  either  acquired  or  hereditary, 
offers  a  suitable  soil  for  the  development  of  the  tu- 
bercular bacilli. 

The  Later  Manifestations  of  Hereditary  Syph- 
ilis.—  In  certain  cases  of  hereditary  syphilis  either 
no  symptoms  whatever  are  noticed  at  birth  or  they 
are  so  indefinite  in  character  that  they  are  not  recog- 
nized as  syphilitic  lesions.  The  lesions  of  hereditary 
syphilis  correspond  to  the  tertiary  stage  of  the  ac- 
quired disease ;  they  appear  at  different  periods  dur- 
ing childhood,  but  especially  about  puberty.  Many 
who  showed  the  infantile  type  of  the  disease,  and  in 
whom  the  evidences  of  the  disease  have  been  abated 
or  have  become  latent,  are  sufferers  from  some  form 
of  the  later  manifestations.  Lesions  of  the  bone 
are  prominent  conditions  during  this  period.  These 
lesions  maybe  in  the  form  of  a  periostitis  or  an  actual 
necrosis.  The  bones  of  the  nose  are  often  involved 
and  flattening  of  the  bridge  is  quite  characteristic. 
Two  ty-pes  of  lesions  of  the  frontal  bones  are  con- 
sidered syphilitic ;  one  where  there  is  a  prominence 
on  either  side  with  a  pronounced  depression  between ; 
the  other  where  there  is  a  prominence  in  the  center 
with  a  flattening  on  either  side,  giving  a  shape  which 


32  PRESENT    STATUS    OF    PEDIATRICS. 

simulates  the  keel  of  a  ship.  These  same  forms  of 
tuberculosis  may  appear  on  other  bones,  and  on  the 
long  bones  give  them  the  appearance  of  curvatures. 

The  first  set  of  teeth  show  nothing  which  is  char- 
acteristic of  syphilis,  though  they  often  present  evi- 
dences of  malnutrition  similar  to  those  which  may  be 
due  to  a  variety  of  causes. 

In  the  permanent  teeth  there  are  several  peculiari- 
ties which  are  due  to  this  inheritance : 

1.  The  teeth  are  apt  to  be  irregular  in  contour  and 
irregularly  placed. 

2.  The  two  upper  middle  incisors  are  hollowed 
out  on  their  cutting  edges,  with  a  central  convexity 
upward. 

3.  The  other  incisors  may  have  deeply  serrated 
cutting  edges. 

4.  Round  or  peg-shaped  teeth  are  often  observed. 

5.  One  or  more  of  the  incisors  or  canine  teeth  may 
be  wanting. 

6.  There  is  often  a  deficiency  of  the  alveolar  arch 
at  the  anterior  part,  so  that  when  the  jaws  are  closed 
the  upper  and  lower  teeth  do  not  come  together. 

Interstitial  keratitis  is  a  frequent  symptom  of  the 
late  form.  It  usually  disappears  under  treatment, 
leaving  no  trace  behind.  Extensive  ulcerations  of  the 
nose  or  pharynx  may  occur  at  any  period  of  childhood. 
A  persistent  form  of  deafness  without  any  special 
lesions  is  sometimes  observed. 

The  nervous  system  is  liable  to  suffer ;  not  as  fre- 
quently as  in  the  acquired  form  of  the  disease,  but 
often  enough  to  give  us  some  data.  Intra-cranial 
syphilis  may  appear  as  a  diffuse  meningitis,  as  local- 


DIATHETIC    DISEASES SYPHILIS.  33 

ized  gummata  or  as  endarteritis.  It  is  characteristic 
of  any  of  these  forms  of  lesions  to  develop  slowly 
and  to  be  accompanied  by  little  or  no  fever.  The 
meningitis  may  evidence  itself  for  several  weeks  only 
by  more  or  less  constant  headache  in  various  parts 
of  the  head;  later  paralysis  of  some  intra-cranial 
nerve  may  appear,  with  evidences  of  a  severe  intra- 
cranial affection. 

The  symptoms  produced  by  syphilitic  gummata  do 
not  differ  from  those  produced  by  any  localized  cere- 
bral tumor,  and  their  recognition  as  such  must  depend 
upon  the  presence  of  other  syphilitic  manifestations 
Endarteritis  is  especially  liable  to  affect  the  arteries 
at  the  base  of  the  brain.  It  may  lead  to  local  dilata- 
tion, with  a  thinning  of  the  arterial  wall,  and  result 
in  a  hemorrhage,  or  there  may  be  produced  an  occlu- 
sion, which  cuts  off  the  blood  supply,  and  result  in 
more  or  less  softening  and  disintegration  of  cerebral 
tissue.  The  symptoms  will  of  course  vary  in  accord- 
ance with  the  part  of  the  brain  affected.  The  most 
common  are  the  various  forms  of  paralysis  of  the  ex- 
tremities and  sensory  disturbances.  Any  of  these 
forms  of  the  disease  are  more  liable  to  yield  to  treat- 
ment than  are  similar  conditions  not  depending  upon 
syphilis. 

Syphilis  of  the  spinal  cord  may  present  itself  as  an 
obliterative  endarteritis  or  as  a  general  arteritis ;  it 
may  or  may  not  be  associated  with  same  condition  in 
the  cranium.  More  often  syphilis  of  the  cord  is  asso- 
ciated with  a  subacute  or  chronic  meningitis  or  me- 
ningo-myelitis.  The  important  features  to  bear  in 
mind  in  either  of  these  forms  of  the  disease  are : 
4 


34  PRESENT    STATUS    OF    PEDIATRICS. 

1.  The  unusual  distribution  of  the  disease  over  the 
greater  part  of  the  cord, 

2.  The  slight  intensity  of  the  affection  at  any  one 
level  as  compared  with  the  extensive  areas  involved. 

3.  The  rapid  improvement  of  some  vsymptoms  and 
■the  persistency  of  others. 

4.  The  frequent  history  of  other  manifestations  of 
the  disease  elsewhere. 

5.  The  fact  that  they  have  a  tendency  to  improve- 
ment and  an  equal  tendency  to  relapses. 

The  mental  development  of  syphiHtic  children  is 
often  retarded;  they  appear  several  years  younger 
than  they  really  are.  The  lesions  of  the  bones  may 
interfere  with  proper  osseous  development  and  dwarf- 
ing be  the  result.  Syphilitic  children  are  late  in  ar- 
riving at  puberty  and  a  diminutive  type  of  the  geni- 
talia may  persist  all  through  childhood. 

Treatment. — The  importance  of  proper  feeding 
and  nutrition  has  been  mentioned.  These  subjects 
are  liable  to  dyspeptic  disorders,  and  especial  care 
will  be  required  to  maintain  nutrition;  the  higher 
the  standard  of  nutrition,  the  better  will  they  respond 
to  our  efforts  and  the  more  perfectly  will  they  out- 
grow the  effects  of  their  vitiated  inheritance.  They 
will  also  demand  the  strict  observance  of  every  hy- 
gienic rule. 

The  medical  treatment  is  as  varied  as  the  mani- 
festations of  the  disease.  I  am  not  one  of  those  who 
find  in  mercurins  the  sole  or  even  the  most  frequently 
indicated  remedy.  Mcrciiriiis  does  not  cover  all  of 
the  symptoms  of  secondary  syphilis,  and  almost  none 
of  those  of  the  tertiary  stage.      Hereditary  syphilis 


DIATHETIC    DISEASES SYPHILIS.  35 

presents  conditions  and  symptoms  corresponding  to 
the  second  and  third  stages  of  the  acquired  disease. 
Mucous  ulcerations,  characterized  by  extensive  in- 
flammation and  swelling,  will  demand  vierctirhis,  also 
some  forms  of  dyspeptic  disorders  and  bone  lesions 
with  nightly  aggravations  of  pain. 

The  catarrhal  inflammations  are  more  apt  to  demand 
some  of  the  various  kali  preparations.  Hereditary 
syphilitic  symptoms,  like  the  kali  pathogeneses,  are 
characterized  by  the  absence  of,  or  low  grade  of  fever. 

KreosoUim  will  often  control  the  foul  smelling  diar- 
rhoeas and  rob  the  child  of  its  usual  peculiar  penetrat- 
ing odor.  It  is  also  of  service  in  controlling  dental 
caries  and  in  healing  the  cracks  and  fissures  at  the 
commissures  of  the  mouth. 

The  iodide  of  potash  is  a  valuable  remedy  with 
which  to  arrest  the  progress  of  lesions  of  the  glandu- 
lar, the  nervous,  and  the  osseous  systems,  but  it  can 
frequently  be  well  followed  or  replaced  by  the  iodide 
of  calcarca  or  the  iodide  of  arsenicu?n  inlesions  of  the 
glands;  hy  silicea  or  zincuin  or  siilpJmr  in  those  of 
the  nervous  system ;  and  by  hepar  sidpJiuris  or  aurunt 
or  nitric  acid  in  those  of  the  osseous  system. 

Mezereuvi,  tJiiija^  or  sulphur  are  remedies  fre- 
quently required  to  clear  up  the  various  skin  mani- 
festations. 

Strictly  homoeopathic  medication  will  yield  the  best 
results  in  the  treatment  of  hereditary  syphilis,  and 
we  do  not  need  very  often  to  resort  to  so-called  anti- 
dotal treatment. 


36  PRESENT    STATUS    OF    PEDIATRICS. 

TUBERCULOSIS.  — In  General.  — All  diseases, 
whether  local  or  general,  which  are  due  to  the  devel- 
opment of  the  tubercle  bacillus  of  Koch  are  now  in- 
cluded in  the  one  general  term — tuberculosis.  The 
lesions  formerly  known  as  scrofulous,  affecting  the 
glands,  bones,  and  skin,  are  recognized  as  of  bacillary 
origin,  and  the  term  "scrofula"  is  rapidly  becoming- 
obsolete.  Nothing  has  come  of  the  theory  advanced 
by  ^Martin  that  recovery  from  scrofulous  lesions  af- 
forded an  immunity  from  pulmonary  tuberculosis. 
On  the  contrary,  it  is  generally  accepted  that  mild 
tubercular  inflammations,  whether  of  the  superficial 
glands,  the  skin,  or  the  bones,  are  a  constant  menace, 
not  only  during  their  period  of  active  inflammation, 
but  also  during  their  period  of  latent  quiescence. 

I  do  not  propose  to  go  into  a  scientific  discussion  of 
the  tubercle  bacillus  and  its  relationship  to  the  dis- 
ease ;  this  has  been  thoroughly  established  by  a  host 
of  better  qualified  observers.  A  study  of  the  bacillus, 
its  methods  of  cultivation,  its  methods  of  life,  and  the 
histological  structure  of  its  ultimate  product,  the  tu- 
bercle, are  not  in  our  province. 

There  are  a  few  general  facts  in  relation  to  it 
which  I  desire  to  state.  The  bacilli  are  tenacious  of 
life  and  retain  their  virulence  after  desiccation  and 
freezing.  Desiccation  and  the  exposure  to  the  air 
lessen  their  virulence  slowly  and  will  in  time  ren- 
der them  sterile.  When  fully  exposed  to  the  direct 
rays  of  the  sun  they  are  destroyed  in  a  few  hours. 
Heat  is  the  surest  agent  for  their  destruction.  Boil- 
ing destroys  their  virulence  in  a  few  minutes,  and  a 
temperature  of  158  degrees  F.  in  distilled  water  for  a 


DIATHETIC    DISEASES — TUBERCULOSIS.  37 

half  hour  is  sufficient  to  destroy  them.  They  with- 
stand a  temperature  of  212  degrees  F.  in  a  dry  me- 
dium for  several  hours  without  losing  their  virulence. 
Outside  of  the  body  they  have  been  shown  to  be  very 
wide-spread,  the  number  in  any  particular  locality  de- 
pending upon  the  number  of  cases  of  tuberculosis  in 
that  locality  and  the  lack  of  precaution  in  sterilizing 
their  sputa.  The  dust  of  cities  and  thickly  crowded 
communities  always  abounds  with  them;  at  the  re- 
sorts for  consumptives  they  can  always  be  found  in 
hotels  and  lounging  places ;  the  upholstering  of  cars 
and  furniture  used  by  consumptives  will  always  yield 
its  quota.  The  dried  sputa,  mingling  with  the  dust, 
traveling  whither  the  wind  blows,  invading  every 
crevice  and  lodging  in  every  resting  place,  is  the  fer- 
tile source  of  the  spread  of  infection. 

It  is  stated  that  the  bacilli  have  been  found  alive 
in  bodies  dead  of  tuberculosis,  two  years  after  their 
burial.  The  contamination  of  water  draining  from 
burying  grounds,  even  distant  by  miles,  is  another 
source  of  contagion. 

That  the  bacillus  is  an  essential  etiological  factor 
in  the  development  of  tuberculosis  is,  we  believe,  ac- 
cepted by  everyone.  With  this  fact  should  always  be 
associated  the  equally  necessary  conditions',  viz. ,  an 
impaired  tissue  and  an  arrest  171  situ  long  enough  to 
obtain  a  foothold.  The  healthy  skin  aud  the  ciliated 
epithelium  of  the  respiratory  tract  afford  a  perfect 
barrier  to  the  invasion  of  the  bacilli.  The  other 
forms  of  epithelium  covering  the  mucous  membrane 
of  the  orifices  of  the  body  is  also  a  successful  barrier 
to  invasion — the  bacilli  cannot  live  in  a  healthy  stom- 

443351 


38  PRESENT    STATUS    OF    PEDIATRICS. 

ach  secreting  normal  gastric  juice,  A  membrane 
robbed  of  its  epithelium  offers  an  open  door  for  in- 
vasion— an  excessive  catarrhal  secretion  offers  a  good 
nidus  for  a  culture.  A  vitiated  gastric  secretion  will 
allow  bacilli  to  enter  the  intestinal  tract  in  possession 
of  their  full  virulence.  A  study  of  the  tissues  drained 
into  the  superficial  and  deep  lymphatic  glands  will 
explain  why  the  bacilli  so  frequently  find  an  entrance 
in  children  to  the  cervical,  bronchial,  and  mesen- 
teric glands.  A  cutaneous  eruption  of  the  face  opens 
the  door  to  the  superficial  cervical  glands.  A  dis- 
eased tonsil  or  a  dental  caries  may  carry  infection  to 
the  deep  cervical  glands.  An  extension  beyond  the 
cervical  glands  or  chronic  catarrh  of  the  pharynx  and 
larynx  will  involve  the  tracheal  glands,  while  the  over- 
flow of  the  latter  is  bound  to  be  into  the  bronchial 
glands.  A  diseased  intestine,  or  even  an  impaired 
stom.ach  digestion,  renders  the  mesenteric  glands  li- 
able to  invasion.  With  the  acceptance  of  the  theory 
that  the  tubercle  bacillus  is  the  etiological  factor  our 
ideas  of  the  methods  of  invasion  have  been  materially 
mxodified.  Hereditary  transmission  is  now  recognized 
as  a  favoring  condition  rather  than  an  essential  factor. 
In  a  few  rare  cases  tuberculosis  has  been  transmitted 
directly  from  the  mother  to  her  offspring.  The  mode 
of  transmission  is  not  at  ail  certain,  but  it  is  prob- 
ably through  the  medium  of  the  placenta,  though 
tuberculosis  of  the  placenta  is  very  rare.  There  is 
no  evidence  to  show  that  a  tuberculous  father  can  di- 
rectly transmit  it  to  his  offspring.  Statistics  show 
that  tuberculosis  is  a  very  rare  cause  of  death  before 
the  completion  of  the  third  month;  that  it  is  an  un- 


DIATHETIC    DISEASES TUBERCULOSIS.  39 

common  cause  of  death  from  the  third  to  the  sixth 
month  of  life;  and  that  it  is  a  rapidly  increasing- 
cause  of  death  from  the  sixth  month  on  through  the 
second  year  of  life.  The  development  of  the  germ 
depends  in  great  measure  upon  the  character  of  the 
tissue  soil.  It  is  being  recognized  that  a  syphilis  and 
a  catarrhal  inheritance  are  factors  in  the  development 
of  the  disease  in  childhood,  second  in  potency  only  to 
the  tubercular  inheritance. 

Inoculation  is  not  a  common  method  of  invasion 
for  children.  Two  sources  have,  however,  been  ob- 
served often  enough  to  attract  attention:  First,  in 
the  performance  of  the  right  of  circumcision,  where 
the  wound  has  been  "cleansed"  by  suction  by  a 
tuberculous  operator;  second,  by  tuberculous  mid- 
wives  who  have  practiced  mouth  to  mouth  inflation 
in  the  new-born. 

Inhalation  of  the  expired  air  of  patients  suffering 
from  tuberculosis  is  not  a  common  method  of  inva- 
sion, but  the  sputa,  dried  and  disseminated  through 
the  air  in  the  form  of  dust,  is  a  very  common  method 
of  invasion.  The  danger  from  this  source  is  very 
tnuch  increased  where  the  patient  and  nurse  are 
closely  related.  This  method  of  invasion  is  least 
common  in  modern  hospitals  where  the  sputa  is  never 
allowed  to  become  dry,  but  is  very  common  in  jails, 
prisons,  convents,  and  factories.  Hotels  and  houses 
where  patients  have  died  of  tuberculosis,  unless  prop- 
erly sterilized,  are  a  standing  menace  to  succeeding 
occupants.  This  fact  explains  in  part  why  members 
of  succeeding  generations  of  the  same  family  suc- 
cumb, especially  in  the  older  cities,  and  detracts  from 


40  PRESENT    STATUS    OF    PEDIATRICS. 

the  force  of  the  family  argument  for  direct  transmis- 
sion by  heredity. 

Ing'estion  of  tuberculized  food  is  one  of  the  most 
common  means  of  invasion  for  children.  The  cow 
is  peculiarly  susceptible  to  tuberculosis,  and  milk 
constitutes  an  important  article  of  food  during 
infancy.  Experimentation  has  proven  conclusively 
that  milk  may  be  infective  even  if  tuberculosis  is 
confined  to  the  lungs  of  the  animal,  and  that  bacilli 
may  be  found  in  the  milk  even  if  there  is  no  dis- 
ease of  the  mammary  gland.  The  virulence  is  re- 
tained in  cream  and  butter.  Other  conditions  are 
necessary  besides  the  ingestion  of  the  tuberculized 
food.  All  children  using  infective  milk  do  not  con- 
tract the  disease.  The  condition  of  the  tissues  may 
not  favor  the  development  of  the  germ ;  the  gastric 
juice  may  destroy  the  germs.  Experimentation  has 
shown,  however,  that  a  lesion  of  the  intestinal  tracts 
is  not  necessary  for  invasion,  but  that  infection  of  the 
mesenteric  glands  may  take  place  through  a  healthy 
mucous  membrane.  The  greater  frequency  of  mes- 
enteric tuberculosis  in  children  finds  its  explanation 
in  these  facts.  What  has  been  said  above  in  refer- 
ence to  infective  milk  applies  to  cows;  that  it  is 
equally  true  of  tuberculous  women  is  probable, 
though  it  has  not  been  definitely  proven  to  be  so. 

The  lesions  produced  by  the  growth  of  bacilli  are 
in  the  form  of  small  nodules,  which,  when  found  to- 
gether, produce  large  infiltrated  areas.  The  studies 
of  bacteriologists  have  pointed  out  accurately  the 
changes  induced  by  the  bacilli  as  follows : 

(i.)  The  nucleated  epithelioid  cells  forming  a  large 


DIATHETIC    DISEASES TUBERCULOSIS.  41 

proportion  of  the  nodule  or  tubercle  are  the  result  of 
the  rapid  growth  and  proliferation  of  the  fixed  tissue 
cells,  viz.,  the  ordinary  epithelium,  the  endothelium 
of  the  capillaries,  and  the  connective  tissue  cells. 
Inside  of  these  epithelioid  cells  bacilli  are  found. 

(2.)  The  round  or  lymphoid  cells  found  around 
the  group  of  epithelioid  cells  are  leucocytes  which 
have  migrated  from  the  neighboring  and  involved 
vessels.  These  cells  do  not  undergo  proliferation, 
but  are  increased  in  number  by  successive  invasions ; 
they  represent  the  efforts  of  Nature  to  combat  the 
bacilli ; — in  the  first  place,  to  absorb  and  carry  off  the 
toxines  manufactured  by  the  invaders,  and,  secondl}^ 
failing  in  this,  to  wall  up  and  encapsulate  the  germs. 

(3.)  A  reticulum  is  usually  visible,  which  has  its 
origin  in  the  connective  tissue  matrix. 

(4.)  Giant  cells  in  varying  numbers  are  usually 
present ;  they  may  be  due  to  cell  growth  without  di- 
vision, or  to  the  fusion  of  several  cells ;  they  contain 
many  nuclei ;  they  are  present  in  an  inverse  ratio  to 
the  number  of  bacilli  in  any  nodule ;  they  are  abun- 
dant in  joint  and  gland  affections  where  the  nu-mber 
and  virulence  of  the  bacilli  are  limited. 

The  tubercle  or  nodule  thus  formed  may  undergo 
caseation  and  necrosis,  or  gradually  become  con- 
verted into  connective  tissue.  By  the  union  of  many 
degenerating  nodules  large  masses  may  be  formed 
w^hich  by  softening  result  in  cavities,  or  by  fibroid 
development  become  encapsulated,  or  by  sclerotic 
processes  become  limited.  In  their  growth  the  tuber- 
cles destroy  tissues,  and,  if  the  bacilli  gain  access  to 
blood  or  lymphatic  vessels,  a  wide-spread  development 
of  nodules  will  result. 


42  PRESENT    STATUS    OF    PEDIATRICS. 

Dijffuse  or  General  Tuberculosis  occurs  in  chil- 
dren, as  in  adults,  in  two  forms,  acute  and  cJironic. 

Acute  miliary  tuberculosis  running  a  rapid  course 
is  decidedly  more  common  in  infants  and  children 
than  in  adults ;  as  a  matter  of  fact  there  is  always  a 
local  infection  either  by  means  of  a  gland  or  a  joint 
or  through  the  skin.  This  primary  infection  may 
have  been  in  existence  for  some  time,  or  it  may  be 
immediately  followed  by  the  diffused  form.  The 
disease  may  present  itself  in  one  or  two  forms,  either 
as  an  acute  affection  without  any  definite  local  symp- 
toms, or  as  an  acute  affection  with  symptoms,  pointing 
to  the  serious  involvement  of  some  particular  organ 
or  tissue.  The  anatomical  peculiarities  of  tubercu- 
losis in  infants  differ  in  some  particulars  from  those 
observed  in  adults,  but  after  three  years  of  age  these 
peculiarities  become  less  noticeable.  As  in  adults, 
the  acute  form  presents  itself  in  three  types, — a  cere- 
bral, a  typhoid,  and  a  pulmonary  type. 

The  cerebral  tuberculosis,  or  tubercular  men- 
ing'itis,  is  peculiarly  an  infantile  type  of  the  disease; 
it  is  frequently  called  basilar  meningitis  because  of  its 
usual  location.  This  form  of  the  disease  is  rare  after 
the  second  year  of  life,  and  is  one  of  the  types  in 
which  heredity  has  been  supposed  to  play  a  most  im- 
portant part.  There  has  been,  however,  no  proof 
produced  that  heredity  does  anything  more  than  to 
prepare  the  proper  soil. 

Infection  can  be  traced  through  the  medium  of  the 
cervical  and  bronchial  glands.  The  proneness  which 
the  disease  shows  to  follow  whooping-cough  or  measles 
is  but  an  evidence  that  the  zvmotic  affection  served, 


DIATHETIC    DISEASES TUBERCULOSIS.  43 

on  the  one  hand,  as  an  exciting  cause  to  light  up  the 
disease  which  was  dormant  in  the  gland,  or,  on  the 
other  hand,  laid  the  glandular  tissue  liable  to  the  in- 
vasion. In  children  the  pia  mater  is  the  seat  of  dis- 
ease, and  usually  that  part  covering  the  base  of  the 
brain.  The  most  favorite  sites  are  in  that  part  of 
the  pia  mater  covering  the  olfactory  nerve,  the  optic, 
and  the  third  nerve.  It  has  a  predilection  to  form 
around  the  small  arteries  and  follow  them  up  to  the 
larger  vessels.  This  location  explains  to  a  certain 
extent  some  of  the  prodromal  symptoms.  The  prod- 
romal stage  in  infants  and  children  may  last  but  a 
week,  and  rarely  more  than  two  weeks.  This  dis- 
ease will  be  found  minutely  described  under  the 
chapter  on  "Diseases  of  the  Brain.  ' 

The  typhoid  type  is  usually  insidious  in  its  onset, 
there  may  have  been  noticed  a  growing  indisposition 
on  the  part  of  the  child  for  a  week  or  two ;  or,  as  is 
often  the  case,  it  may  come  on  suddenly  in  a  child 
who  has  been  supposed,  up  to  that  time,  to  be  per- 
fectly well.  A  bronchial  cough  may,  or  may  not, 
have  preceded  the  attack.  Fever  is  noticed  in  the 
afternoon  or  evening,  a  temperature  which  gradually 
rises  from  day  to  day,  with  partial,  or  at  first  com- 
plete, early  morning  remissions.  Together  with  this, 
there  is  loss  of  appetite,  furred  tongue,  some  abdomi- 
nal distention  and  sensitiveness.  The  child  is  list- 
less, loses  in  weight,  and  in  the  course  of  a  week  is 
sick  enough  to  remain  in  bed.  The  liver  and  spleen 
are  usually  both  enlarged  and  evidences  of  bronchial 
or  pulmonary  disturbance  appear.  The  respiration 
is  increased  only  in  proportion  to  the  rise  in  tempera- 


44 


PRESENT    STATUS    OF    PEDIATRICS. 


ture  and  the  bronchial  symptoms  point  rather  toward 
catarrhal  inflammation  of  the  larger  tubes ;  headache, 
irritability,  and  delirium,  especially  at  night,  are 
usually  present.  The  fever  varies  markedly  in  differ- 
ent cases ;  it  usually  has  nothing  which  stimulates  the 
typical  typhoid  curve.  The  daily  rise  is  more  rapid 
and  may  reach  loi  degrees  F.  in  a  very  short  time. 
In  other  cases  it  ranges  between  loi  degrees  and  102 
degrees  throughout  the  whole  course  of  the  disease. 
As  the  intensity  of  the  disease  obtains,  its  similarity 
to  typhoid  becomes  more  marked ;  the  mouth  becomes 
dry,  the  tongue  furred,  delirium  or  coma  are  present 
or  succeed  each  other;  the  abdomen  becomes  dis- 
tended, tympanitic,  and  hyperaesthetic,  w4th  lack  of 
appetite  and  offensive  exhausting  diarrhoea ;  the  liver 
and  spleen  are  swollen  and  sensitive.  The  differen- 
tiation must  be  made  by  the  absence  of  the  typhoid 
rash,  the  different  temperature  curve,  the  family  or 
personal  history,  the  more  serious  involvement  of  the 
bronchial  tubes,  and  the  presence  of  localized  forms 
of  the  disease.  The  course  of  the  disease  is  very 
variable,  while  death  may  occur  as  early  as  the  be- 
ginning of  the  third  week,  it  is  more  apt  to  be  pro- 
tracted to  the  close  of  the  fourth  or  even  of  the  fifth 
week ;  if  the  disease  continues  as  long  as  the  fourth 
or  fifth  week,  a  tubercular  meningitis,  or  a  distinctly 
pulmonary  form  of  the  disease,  or  some  joint  lesion, 
will  be  set  up  and  any  doubt  removed. 

Pulmonary  Type. — This  is  the  more  common 
form  in  children,  and  will  be  treated  in  the  chapter 
on  ''Diseases  of  the  Chest." 

Chronic  Diffused  Type. — Thisischaracterized»by 


DIATHETIC    DISEASES — TUBERCULOSIS.  45 

the  gradual  development  of  the  tubercular  masses  in 
many  parts  of  the  body ;  these  are  not  tubercles  of 
the  miliary  type,  but  coarse  nodules  of  varying  sizes. 
The  chronic  diffuse  tuberculosis  is  much  more  com- 
mon in  infants  than  in  children  over  two  years  of  age. 
It  presents  a  picture  of  progressive  disturbance  of 
nutrition;  a  continuous  fever  is  rarely  present,  but 
high  grades  of  fever  are  liable  to  occur  as  the  result 
of  otherwise  trivial  disturbances.  The  disease  may 
begin  as  an  acute  catarrhal  bronchitis  or  as  an  attack 
of  broncho-pneumonia,  or  may  follow  measles, 
whooping-cough,  or  any  acute  gastro- intestinal  ca- 
tarrh. Emaciation  is  progressive  and  extreme,  the 
skin  becomes  wrinkled  and  dry,  and  hangs  in  loose 
folds ;  the  thorax  small  and  the  ribs  prominent,  while 
the  abdomen  is  distended,  the  liver  and  spleen  being 
swollen  and  sensitive ;  vomiting,  diarrhoea,  and  a  per- 
sistent cough  are  usually  present.  Fever  is  usually 
absent  and  the  temperature  is  frequently  subnormal. 
These  cases  often  present  a  striking  similarity  to  rha- 
chitis  or  to  hereditary  syphilis ;  the  differentiation  can 
be  made  only  by  the  history  and  a  bacteriological  ex- 
amination of  the  discharges.  Death  usually  occurs 
as  a  result  of  some  complication. 

LOCALIZED  TUBERCULOSIS. 

Tubercular  Adenitis. — The  cervical  lymphatic 
glands  drain  the  structures  of  the  head  and  neck ;  the 
superficial  group  performing  this  duty  for  the  side  of 
the  head,  neck,  and  face,  and  the  external  ear;  the 
deep  group  along  the  carotid  sheath  draining  the 
mouth,  tonsils,  palate,   pharynx,   and  larynx;  while 


46  PRESENT    STATUS   OF    PEDIATRICS. 

the  submaxillary  and  suprahyoid  group  drain  the 
front  of  the  mouth  and  tongue,  the  lower  gums,  the 
chin  and  lower  lips.  A  diseased  tooth,  an  ulcerated 
gum,  an  inflamed  skin,  or  a  naso-pharyngeal  catarrh 
may  open  the  door  for  invasion.  A  tissue  weakened 
by  disease,  malnutrition,  or  vitiated  inheritance  offers 
a  suitable  soil  and  the  bacilli  have  obtained  a  foot- 
hold. This  form  of  tubercular  disease  is  very  com- 
mon, probably  the  most  common,  in  childhood.  This 
is  particularly  the  type  of  invasion  v;hich  was  for- 
merly considered  as  characteristic  of  scrofula.  The 
presence  in  the  gland  of  the  bacilli  or  of  the  ruins  of 
its  life-work  demonstrate  it  to  be  but  one  of  the  va- 
rious forms  of  the  common  disease.  These  glands 
may  enlarge  and  soften  rapidly, — break  down  and 
discharge  with  little  involvement  of  adjacent  tissues. 
More  commonly,  however,  the  enlargement  is  slow 
and  they  may  be  felt  as  hard  lumps  under  the  skin ; 
they  may  gradually  decrease  in  size  and  imdergo 
spontaneous  resolution ;  or  the  enlarged  glands  may 
show  areas  of  softening,  adjacent  tissues  become  in- 
volved, and  the  bacilli  invade  deeper  and  deeper 
glands.  Sinuses  are  established  which  only  empty 
out  a  part  of  the  morbific  products  and  germs,  while 
they  offer  a  ready  means  for  extension.  The  under- 
mining of  the  superficial  tissues  and  the  tortuous  si- 
nuses leave  ugly  disfiguring  scars.  The  majority  of 
these  cases  of  cervical  tubercular  adenitis  are  amen- 
able to  treatment.  Success  depends  upon  the  early 
recognition.  Our  knowledge  of  the  methods  of  inva- 
sion and  extension  should  demonstrate  the  value  of 
early  surgical  extirpation  when  Nature,  aided  by  our 
help,  cannot  prevent  extension. 


DIATHETIC    DISEASES — TUBERCULOSIS.  47 

Tracheo-Bronchial  Adenitis.— Within  the  thorax 
there  are  many  groups  of  lymphatic  glands,  all  of 
which  by  means  of  the  lymphatic  vessels  are  connected 
with  each  other  as  well  as  with  those  of  the  neck. 
Those  most  commonly  invaded  by  the  bacilli  are  the 
tracheal  and  the  bronchial;  they  may  be  involved 
secondarily  as  an  extension  of  the  disease  from  the 
localized  form  of  pulmonary  or  pleural  type,  or  as  an 
involvem.ent  in  the  diffused  type  of  the  disease.  In 
either  case,  growth  is  rapid,  caseation  and  softening 
occur  early ;  new  symptoms  appear  as  a  result  of  their 
implication  and  the  progress  of  the  disease  is  hastened. 
These  glands  may  be  primarily  invaded  and  be  the 
only  foci  of  the  disease,  or  an  extension  of  the  disease 
from  the  cervical  glands  may  be  present  without  any 
general  involvement.  A  very  large  proportion  of  all 
cases  of  tuberculosis  in  children  show  this  method  of 
invasion,  and  this  often  without  any  local  lesion  in  the 
lungs.  The  growth  of  the  glands  may  produce  a  great 
variety  of  symptoms,  as  pressure  may  be  exerted  upon 
the  pneumogastric  nerve,  the  recurrent  laryngeal 
nerve,  the  pulmonary  veins,  the  trachea,  and  the 
bronchi.  The  breaking  down  and  discharge  of  the 
softened  glands  involves  other  tissues  and  is  often  the 
beginning  of  a  diffused  type;  the  most  frequent  exit 
for  the  discharge  is  into  the  bronchi.  In  the  begin- 
ning of  tracheo-bronchial  tubercular  adenitis  the  ma- 
jority of  cases  show  no  definite  signs ;  a  slight  rise  in 
temperature  of  the  tubercular  type,  a  dry  cough,  are 
often  the  only  symptoms  to  be  observed,  and  if  not 
associated  with  a  faulty  history  are  not  apt  to  attract 
attention. 


48  PRESENT    STATUS    OF    PEDIATRICS. 

Mesenteric  Tubercular  Adenitis  (Tades  vieseyi- 
t erica). — The  mesenteric  and  retroperitoneal  glands 
are  often  invaded  by  tubercular  inflammation.  In 
children  it  is  often  the  primary  form  of  invasion  and 
has  often  been  found  accidentally  at  post-mortem 
examination  where  it  had  not  previously  been  sus- 
pected. A  lesion  of  the  intestine  is  not  considered 
essential  to  the  invasion.  The  early  symptoms  are 
those  of  disordered  digestion,  and  peritoneal  inflam- 
mation ;  later  we  find  persistent  diarrhoea  with  offen- 
sive stools,  inordinate  craving  appetite  Avith  extreme 
emaciation.  With  the  advance  of  the  disease  the  ab- 
dominal organs  are  first  involved  and  later  more  dis- 
tant organs;  with  the  involvement  of  the  lungs  or 
meninges  the  usual  rapid  course  of  these  types  of  the 
disease  is  instituted. 

Tuberculosis  of  the  Alimentary  Tract  {Con- 
sumption of  tJie  Bozvels). — The  intestinal  form  of  the 
disease  in  children  may  be  primary,  but  in  the  greater 
majority  of  cases  is  secondary  to  a  general  type  or  to 
a  primary  mesenteric  form.  The  primary  type  is 
due  to  the  ingestion  of  contaminated  food,  as  tuber- 
culized  milk,  while  chronic  catarrhal  inflammation  of 
the  intestines  are  present.  This  undoubtedly  ex- 
plains why  it  is  common  only  to  young  children.  The 
secondary  type  is  often  due  to  the  swallowing  of 
tuberculized  sputum.  The  ileum  is  the  favorite  seat 
of  the  disease  and  Peyer's  glands  the  most  vulner- 
able points. 

Tuberculosis  of  the  Liver. — The  liver  is  not 
usually  involved  except  as  a  part  of  a  general  tuber- 
culosis.     We  find  either  a  large  number  of  miliary 


DIATHETIC    DISEASES — TUBERCULOSIS.  49 

tubercles  or  large  nodules  which  soften  rapidly.  This 
latter  form  sometimes  honey-combs  the  organ  with 
abscesses.  The  so-called  tubercular  cirrhosis  of  the 
liver  does  not  occur  in  children. 

Tuberculosis  of  Serous  Membranes.— r?/<^^r- 
culosis  of  the  Pleura  is  usually  secondary  to  pulmo- 
nary infection  or  to  disease  of  the  bronchial  glands. 
Purulent  pleurisies  are  usually  associated  with  lobar 
or  broncho-pneumonia,  and  in  a  certain  proportion  of 
cases  are  undoubtedly  tuberculous. 

Tuberculosis  of  the  Pericardium. — This  is  a  fre- 
quent disease  of  children,  but  is  almost  invariably 
associated  with  disease  of  the  bronchial  or  medias- 
tinal glands. 

Tuberculosis  of  the  Peritoneum. — Tuberculosis  is 
one  of  the  most  common  causes  of  peritonitis  in  chil- 
dren. It  occurs  more  frequently  in  boys  than  in  girls 
and  more  frequently  between  the  eighth  and  tenth 
year  of  life  than  either  before  or  after  this  period. 
The  dise~se  may  be  primary  in  the  peritoneum,  but 
is  more  commonly  due  to  an  extension  of  the  dis- 
ease from  the  intestines,  the  mesenteric  glands,  or 
the  genital  organs.  Either  the  miliary  form  of  tuber- 
cles studding  the  whole  peritoneum  may  be  present, 
or  they  may  occur  as  gray  granulations  with  or  with- 
out exudate,  or,  what  is  common  in  children,  the 
tubercles  are  in  the  form  of  caseous  nodules  or  form- 
ing tuberculous  plaques.  The  exudate  is  purulent 
and  the  tissues  become  matted  together.  The  inflam- 
mation may  be  confined  to  some  one  part  of  the  peri- 
toneum, as  the  pelvis  or  lesser  peritoneal  cavity,  be 
saculated,  and  form  a  definite  tumor.  It  may  involve 
5 


50  PRESENT    STATUS    OF    PEDIATRICS. 

the  intestine  in  such  a  way  as  to  produce  occlusion  by 
the  compression  of  large  caseous  masses  or  by  the 
formation  of  connective  tissue  bands,  or  the  intensity 
of  the  inflammation  may  be  in  the  central  portion  of 
the  abdomen,  a  definite  cyst  be  formed  which  dis- 
charges at  the  umbilicus,  leaving  an  open  sluggish 
fistula.  The  tubercular  inflammation  is  often  accom- 
panied by  an  ascitic  exudation.  The  ascitic  accu- 
mulation may  become  encysted  and  point  toward 
the  surface,  and  very  good  results  have  followed 
surgical  interference  and  free  evacuation.  There  is 
nothing  definite  in  the  symptoms  to  differentiate 
tubercular  from  other  forms  of  peritonitis.  The  tem- 
perature curve,  if  fever  is  present,  the  history,  the 
emaciation,  and  the  tendency  to  the  formation  of  en- 
capsulated cysts  are  all  suggestive.  The  presence  of 
the  bacilli  is  the  only  positive  sign. 

Tuberculosis  of  the  Lungs. — This  condition  is 
treated  under  the  chapter  on  ' '  Diseases  of  the  Chest. " 

Renal  Tuberculosis. — As  a  part  of  diffuse  tuber- 
culosis, affections  of  the  urinary  organs  are  more 
common  in  childhood  than  in  adult  life.  The  kidney 
is  more  frequently  affected  than  any  other  part  of 
the  renal  tract.  It  may  be  primary  and  affect  only 
one  kidney.  Primary  tuberculosis  of  the  bladder  or 
ureters  is  very  rare ;  when  affected  it  is  by  an  exten- 
sion from  the  pelvis  of  the  kidney  or  from  the  pros- 
tate gland,  the  epididymis,  or  seminal  vesicles.  The 
urine  is  usually  increased  in  frequency  and  in  amount 
and  contains  mucus,  pus,  kidney  and  bladder  detritus, 
blood,  and  bacilli.  Irregular  fever  and  chills  are  com- 
mon. When  the  bladder  is  affected  all  the  symptoms 
of  cystitis  are  present. 


DIATHETIC    DISEASES — TUBERCULOSIS.  5  I 

Tuberculosis  of  the  Testes.— The  testes  are  fre- 
quently involved  as  a  part  of  the  diffuse  disease  and 
primary  tuberculosis  of  these  organs  is  not  rare.  The 
presence  of  nodular  masses  in  the  testicles  may  be  of 
help  in  determining  the  character  of  some  obscure 
intestinal  or  abdominal  affection.  The  tubercles  may 
break  down  and  suppurate,  form  adhesions  to  the  skin, 
and  discharge  through  persistent  sinuses.  In  such 
cases  the  testicles  will  become  very  much  enlarged. 

Tuberculosis  of  the  Uterus  and  Adnexa.— 
These  organs  are  very  rarely  primarily  affected  in 
children,  though  their  involvement  in  diffuse  types  of 
the  disease  is  not  uncommon. 

Tuberculosis  of  Bone. — Tuberculosis  of  the  bones 
is  not  a  primary  form  of  the  disease,  but  is  due  to  the 
emigration  of  the  bacilli  from  other  foci  through  the 
medium  of  the  blood.  It  is  found  in  a  variety  of 
forms,  as  osteomyelitis,  hip  disease,  spinal  caries,  ab- 
scesses, etc.  It  is  not  always  easy  to  differentiate  the 
tuberculous  from  other  forms  of  bone  inflammations. 
A  daily  rise  of  temperature  of  not  more  than  one- 
half  of  a  degree  is  always  a  suspicious  symptom ;  a 
faulty  inheritance  may  help  in  the  diagnosis.  Pro- 
gressive ansemia  and  tenderness  are  also  early  symp- 
toms. Senn  states  that  "in  ninety- five  out  of  every 
hundred  cases  chronic  inflammation  of  the  bone  means 
tuberculosis."  The  hypodermic  needle  will  yield 
fluid  in  which  the  presence  or  absence  of  the  bacilli 
may  be  determined.  If  the  location  of  the  disease 
is  in  an  accessible  part,  we  look  for  good  results  when 
the  progress  has  been  slow  and  the  patient's  general 
health  has  been  good.  Absolute  rest  is  a  si7ie  qua  non 
for  improvement.     Everything  which  improves  the 


52  PRESENT    STATUS    OF    PEDIATRICS. 

patient's  general  health  is  of  value,  and  surgical  in- 
terference is  often  required. 

Tuberculosis  of  Joints. — These  inflammations 
are  usually  chronic  and  secondary  forms  of  the  dis- 
ease. The  bacilli  are  brought  by  the  circulation  and 
localized  in  the  joint  by  some  slight  bruise  or  strain. 
The  disease  may  be  primary  in  the  synovial  mem- 
brane or  in  the  bone.  The  disease  is  usually  curable 
if  early  recognized.  There  is  liable  to  be  some  im- 
pairment of  the  joint.  Immobilization  of  the  joint 
and  attention  to  the  general  health  are  essential 
features  in  the  cure.  Evacuation  of  effusion  and  re- 
moval of  diseased  tissues  are  often  demanded. 

Prophylaxis. — Proper  prophylactic  care  depends 
upon  a  thorough  understanding  of  the  methods  of  in- 
fection. To  prevent  infection  through  the  inhala- 
tion of  germ-laden  dust  the  sputum  and  all  excre- 
tions of  the  tuberculous  should  be  immediately 
sterilized  or  destroyed  and  never  allowed  to  become 
dry.  A  consumptive  should  never  be  allowed  to 
spit  into  anything  but  a  proper  receptacle  prepared 
for  that  sole  purpose.  The  sources  of  food  should 
be  carefully  investigated,  and  milk  from  tuberculous 
cows,  and  tuberculized  meat  should  be  kept  out  of  the 
market.  Foods  of  all  kinds,  and  particularly  milk, 
butter,  cheese,  and  meat,  should  be  guarded  from  ac- 
cidental infection.  The  only  absolute  safeguard  is  of 
course  sterilization  by  heat.  Children  born  of  tuber- 
cular parents,  or  of  parents  whose  health  has  been 
impaired,  are  fit  subjects  for  the  disease.  Children, 
by  their  habits,  are  more  likely  to  open  some  avenue 
for  invasion  than  adults.  A  greater  variety  of  things 
find  their  way  into  children's  mouths.      Infants  creep- 


DIATHETIC    DISEASES — TUBERCULOSIS.  53 

ing  around  the  floor  with  some  morsel  or  plaything 
in  their  hands,  which  makes  alternate  trips  between 
the  floor  and  their  mouths,  open  the  avenue  to  the 
mesenteric  glands  and  alimentary  tract.  Many  of 
the  children's  ailments  prepare  a  proper  soil  for  the 
bacilli ;  notably  is  this  true  of  catarrhal  inflammations, 
measles,  and  whooping-cough.  Individual  prophy- 
laxis then  should  include  the  following  points : 

1.  Rigid  quarantine  from  tuberculosis  patients. 

2.  Sterilization  of  all  suspected  foods. 

3.  The  prevention  of  all  catarrhal  inflammations. 

4.  The  speedy  cure  of  catarrhal  inflammations  when 
they  exist,  using  some  means,  when  possible,  to  fre- 
quently wash  away  all  secretions. 

5.  The  prevention  of  mouth  breathing. 

6.  A  regularity  of  habits  which  will  be  most  con- 
ducive to  good  general  health. 

7.  A  methodical  physical  training,  especially  of 
weak  tissues  and  organs. 

8.  Selection  of  a  locality  where  the  child  can  live 
out  of  doors  the  greatest  possible  amount  of  time. 

9.  Life  in  the  country  away  from  the  resorts  of  con- 
sumptives. 

The  great  majority  of  cases  of  tuberculosis  in 
children  are  preventable,' and  the  more  one  studies 
the  disease  in  its  various  aspects,  the  more  he  will  be- 
come impressed  with  the  fact  that  this  great  scourge 
lives  mainly  by  reason  of  ignorance  and  neglect  on 
the  part  of  both  the  profession  and  the  laity. 

Treatment. — In  the  treatment  of  tuberculous  pa- 
tients" the  question  of  feeding  and  environment  are 
equally  important  as  in  the  prevention  of  the  disease. 
Sunshine,  out-of-door  life,  residence  in  equable  cli- 
mates, and  purity  of  the  air  are  our  best  allies.  Sys- 
tematic feeding  is  second  to  nothing  in  importance 


54  PRESENT    STATUS    OF    PEDIATRICS. 

for  the  welfare  of  the  tuberculous  patients.  Milk  and 
cream,  when  pure,  should  constitute  an  important 
factor  in  the  dietary  of  every  tuberculous  patient. 
Predigested  milk  is  often  a  very  useful  food  for  chil- 
dren. Cod  liver  oil  owes  its  value  and  popularity 
mainly  to  the  fact  that  it  contains  a  good  animal  fat. 
I  have  found  the  preparation  of  cod  liver  oil  with 
Maltine  usually  palatable,  and  I  believe  it  has  been 
of  value  as  a  food  for  many  patients. 

The  use  of  Koch's  tiiberciilinmn  by  injection  has 
been  found  of  value  in  some  cases,  but  in  others  the 
reaction  has  seemed  to  hasten  the  progress  of  the 
disease ;  to  be  of  value  it  must  be  used  early  in  the 
disease.  Personally  I  have  had  no  experience  with 
its  use.  Some  of  our  physicians,  notably  Dr.  B.  S. 
Arnulphy  of  Chicago,  report  very  good  results  from 
the  use  of  the  tuberctiliniivi  potentized  and  adminis- 
tered internally.  Dr.  Arnulphy  uses  it  mainly  in  the 
thirtieth  potency. 

The  injection  of  iodoform  into  tuberculous  joints, 
glands,  and  cavities  has  been  practiced  quite  exten- 
sively and  has  seemed  in  many  cases  to  have  been 
followed  with  good  results.  It  has  also  been  poten- 
tized and  used  internally  in  the  lower  potencies  by 
some  members  of  our  school.  Good  results  are  claimed 
by  many  observers,  especially  in  joint  affections. 

The  JiypopJiospJiites  of  livie,  soda,  and  potash  have 
been  in  use  for  years  and  are  of  undoubted  value,  in 
the  incipiency  of  the  disease,  as  constructive  agents. 
It  is  far  preferable  to  select  the  one  which  meets  the 
requirements  of  the  individual  case  and  prescribe  that 
alone  in  a  simple  form,  as  a  trituration,  than  to  em- 
ploy the  trade  compounds  in  the  market. 


DIATHETIC    DISEASES — TUBERCULOSIS.  55 

Of  late,  preparations  of  blood-elaborating  glands 
and  constructive  organs,  as  the  pancreas  and  bone 
marrow,  have  been  quite  extensively  used.  I  have 
used  the  preparation  known  2i^  protomiclein  in  a  num- 
ber of  cases  during  the  past  year,  including  tubercu- 
losis of  the  cervical,  bronchial,  and  mesenteric  glands, 
tuberculosis  synovitis,  and  incipient  pulmonary  tuber- 
culosis. It  has  not  been  used  to  the  exclusion  of 
homoeopathic  remedies,  and  therefore  its  value  in 
these  cases  is  problematical.  They  have  been  mainly 
hospital  cases,  unfavorable  subjects  under  constant 
observation,  and  the  results  obtained  have  in  many 
instances  been  very  gratifying.  I  am  impressed  with 
its  value,  to  the  extent  that  I  am  at  present  using  it 
alone  in  two  cases ;  one  a  tuberculous  synovitis  of  the 
knee,  and  the  other  tuberculous  cervical  and  tracheal 
glands. 

Any  form  of  local  treatment  which  rids  the  tissue 
of  necrosed  matter,  excessive  secretions  of  bacilli 
and  their  toxines  is  of  value,  if  it  does  not  introduce 
any  disease  producing  influence.  This  is  equally 
true  whether  glands,  joints,  cavities,  or  mucous  sur- 
faces are  involved. 

The  value  of  well-proven  homoeopathic  remedies 
in  tuberculosis  has  been  firmly  established  and  is  of 
far  greater  importance,  so  far  as  medication  is  con- 
cerned, than  anything  else  that  can  be  recommended. 
Iodine  and  its  compounds  stand  out  pre-eminently  first. 
Sulphur  and  calcarea  and  their  compounds  probably 
rank  next  in  their  frequency  of  use.  I  shall  not 
undertake  to  give  any  directions  for  their  selection, 
for  we  all  know  where  to  look  for  such  information, 
and  there  is  nothing  new  to  offer. 


56  PRESENT    STATUS    OF    PEDIATRICS. 


CHAPTER  III. 


REFLEXES. 

BY  C.  A.  WEIRICK,  M.  D. ,  EX-PRESIDENT  ILLINOIS  HOMCEOPATHIC 
STATE  MEDICAL  ASSOCIATION;  EX-PRESIDENT  HOMCEOPATHIC 
MEDICAL  SOCIETY  OF  CHICAGO  ;  ADJUNCT  PROFESSOR  OF  PHYSI- 
OLOGY, CHICAGO  HOMCEOPATHIC  MEDICAL  COLLEGE  ;  LECTURER 
LINCOLN  PARK  AND  GARFIELD  PARK  TRAINING  SCHOOLS  FOR 
NURSES,   CHICAGO. 

Two  forces  are  constantly  exercised  in  the  human 
organism,  viz.,  reproduction  and  destruction.  The 
former  is  carried  on  by  all  the  great  functions  of  the 
body, — digestion,  absorption,  respiration,  circulation, 
and  secretion,  each  an  important  and  essential  factor 
in  the  one  great  act,  nutrition,  which  not  only  creates 
the  anatomical  elements  of  a  new  being  and  con- 
stantly repairs,  or  strives  to  repair,  those  of  an  exist- 
ing organism,  but  also,  at  the  same  time,  stores 
within  these  elements  a  potential  energy  that  is  in- 
variably liberated  and  set  in  action  to  reproduce  and 
to  destroy.  If  the  power  which  liberates,  renders 
active,  and  controls  this  energy  or  force  be  neither 
too  great  nor  too  small, — just  sufficient  to  maintain* a 
proper  co-ordinate  organic  action,  then  in  the  body 
will  production  be  equal  to  or  in  excess  of  destruction, 
thereby  resulting  in  health  and  physical    develop- 


REFLEXES.  57 

ment;  but  if  an  insufficient  amount  of  this  latent 
energy  be  changed  to  active  force  or  work  and  heat, 
then  a  slow,  insidious  degeneration  of  one  or  more 
tissue  elements  occurs,  often,  however,  preceded  by- 
diminution  of  functional  activity.  If  an  amount  in 
excess  of  the  maximum  permissible  in  constructive 
metabolism  be  changed  into  kinetic  energy,  then  the 
physiological  acts  and  anatomical  structure  of  the  tis- 
sues are  rapidly  modified  and  altered. 

Health  then  is  the  production  of  potential  or  re- 
serve energy,  and  the  proper  expenditure  of  the 
same ;  disease  is  a  failure  either  to  develop  this  force 
or  to  expend  it  in  the  harmonious  activity  of  all  the 
elements,  tissues,  organs,  and  functions  of  the  body. 
Disease  is  chronic  or  acute,  either  as  an  insufficient 
or  an  excessive  amount  of  energy  at  rest  is  changed 
to  activity.  The  development  of  this  force  and  the 
regulation  of  its  expenditure  therefore  come  within 
the  province  of  the  physician.  Those  forces  which 
liberate  other  forces  are  known  as  stimuli.  They  may 
be  either  chemical,  electrical,  mechanical,  psychical, 
or  that  negatively  defined  force  known  as  vital,  which 
last,  in  children  at  least,  depends  upon  heredity. 
Because  of  their  anatomical  connection  by  means  of 
the  nervous  system,  no  organ,  or  at  least  no  visceral 
organ,  is  independent  of  any  other ;  hence,  a  natural 
stimulus  applied  to  one  directly  or  reflexly,  influences 
the  normal  action  of  another,  providing  one  or  more 
of  the  factors  essential  to  a  reflex  movement  be  not 
destroyed,  even  though  they  may  be  impaired.  It  is 
therefore  a  logical  deduction,  that  if  the  liberating 
force  and  the  three  factors  of  a  reflex  arc,  the  center 


58  PRESENT    STATUS    OF    PEDIATRICS. 

of  reflexion,  the  centripetal  and  centrifugal  fibers,  bo 
normal,  the  body  will  be  in  a  state  of  health. 

Reflex  phenomena  depend  upon  the  condition  ot 
the  reflex  arc  and  the  character  of  the  stimuli,  most 
frequently  upon  the  transferring  center  of  the  arc  lo- 
cated either  in  the  sympathetic  ganglia  or  in  the 
cerebro-spinal  centers.  If  the  center,  the  cause  of 
action  or  inaction  is  central ;  if  the  stimuli,  peripheral. 
In  a  crude  manner  the  reflexes,  especially  that  of  the 
patellar-tendon  and  next  the  ankle  clonus,  have  been 
used  as  means  of  diagnosis  to  determine  well  devel- 
oped abnormal  conditions. 

I  believe  the  time  is  not  far  distant  when  it  will  be 
possible  to  determine,  probably  by  the  aid  of  electric- 
ity and  suitable  apparatus,  the  minimum  and  maximum 
amount  of  energy  necessary  in  the  transferring  cen- 
ters to  maintain  the  proper  degree  of  harmony  in  or- 
ganic action.  Then  will  it  be  possible,  by  an  earlier 
diagnosis  than  it  is  now  possible  to  make,  to  prevent 
the  development  of  some  of  the  incurable  neurotic 
and  reflex  diseases. 

In  Pneumonia. — Perhaps  in  no  other  form  of  acute 
disease,  especially  in  children,  is  the  energy  of  the 
reflection  center  reduced  below  the  minimum  of 
health,  or  even  exhausted,  as  in  catarrhal  pneumo- 
nia,— one  of  the  most  serious  diseases  of  early  life. 
The  cough  often  ceases  though  there  be  no  im- 
provement in  the  pathological  condition,  and  there 
may  even  be  an  extension  to  and  an  involvement  of 
other  lobules  of  the  lungs.  The  inflammation  pro- 
duces the  stimulus,  the  energy  which,  transmitted  by 
the  superior  and  inferior  branches  of  the  vagus,  in 


REFLEXES. 


59 


this  case  the  efferent  fibers,  to  the  cough  center, 
hberates  a  force  that  is  conveyed  by  the  efferent 
fibers  in  the  nerves  of  expiration  to  their  periphery, 
resulting  in  cough.  Then,  if  the  inflammation  be  the 
stimulus  and  it  is  not  abated,  why  does  not  the  patient 
continue  to  cough  and  by  that  means  prevent  an  oc- 
clusion of  the  smaller  bronchi  by  an  accumulation  of 
mucus?  The  potential  energy  of  the  transferring 
center  has  become  exhausted,  hence  there  is  no  power 
for  the  stimulus  to  discharge  through  the  efferent 
fibers  of  the  reflex  arc  to  the  contractile  tissue  in- 
volved in  the  production  of  cough.  This  condition  is 
critical  and  often  followed  by  death.  The  practical 
lesson  to  be  drawn  from  this  experience  and  the  re- 
sults of  its  development  is  to  sustain  the  vigor  of  the 
cerebro-spinal  axis,  in  which  is  found  the  cough  cen- 
ter, by  remedies  acting  upon  it  and  thereby  prevent 
its  exhaustion,  which  is  so  frequently  followed  by  fatal 
results.  The  statement  that  this  may  be  done  is  cor- 
roborated by  clinical  experience.  No  drugs  will  be 
mentioned,  as  it  would  doubtless  lead  to  a  discussion 
of  the  general  treatment  of  this  form  of  pneumonia, 
which  is  not  within  the  scope  of  the  paper.  It  will 
occur  to  all  that  in  many  cases  of  this  disease  the 
cough  does  not  suddenly  cease,  but  gradually  subsides 
with  the  abatement  of  the  pathological  condition ;  it 
IS  so  because  the  potential  energy  of  the  reflex  cough 
center  has  not  become  exhausted  either  by  the  involve- 
ment of  a  large  area  of  lung  tissue  or  by  constitu- 
tional dyscrasia. 

Because  the  organs  are  interdependent  (?)  in  action, 
their  reflex  influence  should   be  considered  in  the 


6o  PRESENT    STATUS    OF    PEDIATRICS. 

treatment  of  any  one  of  them,  not  only  in  chronic  but 
in  acute  diseases. 

Digestive  Sphere.  —  While  improper  food  is 
doubtless  the  most  frequent  etiological  factor  in 
the  production  of  diarrhoea  of  children,  yet  there 
are  not  a  few  cases  of  this  disease  that  are  caused, 
not  by  direct  irritation  of  the  digestive  tract,  but 
by  reflex  influences.  The  power  of  intense  mental 
conditions  to  produce  greatly  exaggerated  peristal- 
sis and  involuntary  defecation  has  been  frequently 
noticed,  especially  from  fright  or  any  other  sudden 
abnormal  mental  action.  Diarrhoea  is  also  caused 
in  infants  by  changing  the  material  composing 
the  garments  worn  next  to  the  skin.  This  is  fre- 
quently observed  when,  even  in  the  hot  temperature 
of  July  and  August,  the  clothing  worn  next  the  skin 
is  changed  from  woolen  to  cotton  goods.  I  have 
often  seen  cases  originating  from  this  cause  rapidly 
cured  by  replacing  the  cotton  by  the  woolen  garment. 
It  is  a  well  attested  fact  that  sudden  atmospheric 
changes  are  productive  of  increased  sickness  and  fre- 
quently increase  the  intensity,  especially  in  this  lati- 
tude, of  gastro-enteric  disorders  during  the  month  of 
September.  Unseasonable  weather,  that  is,  a  cold 
summer  and  warm  winter,  is  accompanied  with  an 
increased  amount  of  sickness.  This  is  not  brought 
about  by  any  direct  local  atmospheric  effect,  either 
mechanical  or  chemical,  upon  the  tissues  involved,  but 
by  a  change  of  stimuli  acting  on  the  peripheral  nerve 
terminations,  probably  of  the  integument,  thereby 
either  diminishing  or  increasing  the  power  of  the  in- 
hibitory and  motor  centers,  and  therefore  changing 


REFLEXES.  6l 

their  reflex  energy,  resulting  in  functional  and  organic 
changes  of  organs  subject  to  their  influence.  It  is 
not  an  uncommon  experience  in  the  treatment  of 
gastro-enteric  diseases  of  infancy  to  be  annoyed  and 
chagrined  by  frequent  recurrence  of  the  attack  in 
the  same  cases,  notwithstanding  the  diet  and  remedies 
have  been  selected  with  the  greatest  care  and  skill. 
As  impaired  glandular  secretion,  both  in  quality  and 
quantity,  and  hyperaemia  and  inflammations  may  be 
caused  by  the  reflex  influence  of  a  cold  draught  act- 
ing on  some  portions  of  the  skin,  it  is  logical  to  con- 
clude, especially  as  clinical  results  verify  the  deduc- 
tion, that  intelligent  care  of  the  surface  of  the  body 
will  prevent  its  undue  stimulation  and  therefore  pro- 
tect from  deleterious  reflex  influences  the  already 
weakened  digestive  organs  and  prevent  frequent  re- 
lapses of  diarrhoea  in  children.  Diarrhoea  again  may 
be  produced,  not  by  direct  irritation  of  the  intestinal 
canal  by  the  presence  of  indigestible  food,  but  by  re- 
flex mental  influences.  The  power  of  intense  mental 
conditions  to  cause  greatly  exaggerated  peristalsis 
and  involuntary  stools  has  been  frequently  observed, 
especially  from  fright.  Cases  of  constipation  also 
may  result  from  the  same  mental  influences  that  in 
others,  by  reflex  action,  are  followed  by  diarrhoea. 
Why  the  same  exciting  cause  is  followed  by  an  over- 
action  in  one  person,  an  insufficient  action  in  another, 
and  of  no  effect  in  a  third,  is  doubtless  due  to  the  dif- 
ferent conditions  of  the  reflex  arc  and  the  influence  of 
the  stimuli,  not  only  upon  the  motor  but  the  inhibi- 
tory centers.  If  the  resistance  of  the  former  were 
decreased  and  the  latter  unchanged,  then  diarrhoea 


62  PRESENT    STATUS    OF    PEDIATRICS. 

would  follow ;  if  the  vice  versa,  constipation ;  but  if 
they  were  both  active,  and  no  relative  change  in  their 
resisting  power,  the  stimuli  would  produce  neither 
constipation  nor  diarrhoea. 

The  delicacy  of  the  mechanism  of  the  reflex  struct- 
ures, and  the  many  changes  their  action  may  produce 
in  the  character  of  a  disease,  especially  in  diarrhoea, 
teach  the  necessity  of  careful  discrimination  in  the 
selection  of  remedies  which  are  very  similar  in  their 
action.  The  many  fine  points  of  difference  between 
drugs  are  therefore  not  to  be  ignored,  especially  in 
the  treatment  of  diarrhoea.  By  teaching  a  more  care- 
ful comparison  between  drugs  that  have  a  somewhat 
similar  line  of  action,  homoeopathy  has  done  much  for 
medical  science  that  is  worthy  of  commendation. 

Again,  in  diarrhoea  it  will  be  noticed  that  the 
indigestible  food  in  the  intestinal  tract,  the  patho- 
logical condition  of  the  same,  or  whatever  other 
cause  may  constitute  the  stimuli,  there  will  be  in 
addition  to  the  altered  contents  of  the  intestines  only 
increased  peristalsis;  sometimes,  however,  this  in- 
creased action  does  not  occur  even  though  the  stools 
be  diarrhoeic  in  character.  This  abnormal  action 
represents  only  a  simple  reflex  response  on  the  part 
of  the  muscular  coat  of  the  intestine ;  but  when  the 
discharging  stimulus  is  very  strong,  or  there  is  an  ex- 
cessive degree  of  excitability  of  the  transferring  cen- 
ter, then  will  inco-ordinate  reflex  manifestations  ex- 
hibit themselves  in  the  form  of  spasms.  It  has  been 
noted  by  Henry  Hartshorne,  M.  D.,  that  more  males 
than  females  die  from  cholera  infantum.  Now,  as  the 
former  are  not,  as  in  adult  life,  more  exposed  to  the 


REFLEXES. 


63 


inclemency  of  the  weather  than  the  latter,  and  as  the 
food  and  clothing  are  the  same  for  both  sexes  during 
infancy,  it  will  be  a  reasonable  deduction  to  conclude 
that  the  cause  of  greater  mortality  in  the  one  sex 
must  be  due  to  some  abnormal  condition  of  the  geni- 
tal organs.  These  parts  should  be  examined.  This 
is  not  stereotyped  advice  given  in  connection  with  the 
care  of  cholera  infantum,  as  all  well  know,  but  because 
the  rate  of  mortality  is  so  uniformly  reported  high, 
the  physician  is  warranted  in  getting  out  of  the  well 
worn  path  of  treatment  which  too  often  leads  to  death 
of  the  child.  Of  course,  it  is  far  better  to  ascertain,  be- 
fore any  acute  condition  manifests  itself,  that  not  only 
are  the  genital,  but  all  other  organs  free  from  condi- 
tions that  will  impair  the  normal  bodily  resistance.  If 
such  conditions  exist,  cure  them  if  possible  before 
they  weaken  the  organism  by  their  reflex  influence, 
and  thereby  act  as  a  predisposing  cause  of  disease. 

Examples  of  Reflex  Action.— I  think  as  a  rule 
physicians  are  inclined  to  ignore  the  small  abnor- 
mal conditions  of  the  body  which  act  as  stimuli,  for 
the  reason  that  they  do  not  produce  acute  disease 
or  because  they  forget  that  a  weak  stimulus  existing 
for  a  short  time  may  not  cause  a  reflex  act ;  but  if 
it  be  continued  may  produce  this  act.  Had  Nature 
intended  to  protect  the  body  only  against  large  foci 
of  irritation,  it  would  have  made  the  nerves  large, 
like  the  muscular  system;  but  many  of  them  are 
microscopical  and  ramify  through  every  part  of  the 
body,  being  especially  numerous  in  the  more  exposed 
parts  of  the  body.  They  are  so  very  susceptible  to 
stimuli  that  one  of  their  functions  no  doubt  is  to  give 


64  PRESENT    STATUS    OF    PEDIATRICS. 

prompt  warning  of  an  assault,  no  matter  how  trivial,  on 
the  vital  force.  A  small  source  of  irritation  continu- 
ously exerted  decreases  its  power  of  resistance.  For 
example,  a  very  small  foreign  substance  in  the  eye 
may,  if  not  removed,  cause  destruction  of  its  fellow ;  the 
presence  of  some  indigestible  substance  in  the  intes- 
tinal tract  may  produce  convulsions  and  sometimes 
death.  Still  another  familiar  example  may  be  given, 
viz. ,  a  small  piece  of  secundines  will  produce  hemor- 
rhage, not  because  it  is  large  enough  to  prevent  con- 
traction, but  because  of  reflex  influence.  If  then  such 
weak  stimuli  will  produce  serious  functional  derange- 
ments in  adult  life,  it  is  not  strange  that  it  will  have 
a  deleterious  influence  in  child  life;  and  while  the 
harm  may  not  be  manifested  at  once,  still  the  loss  of 
recuperative  power  so  often  given  as  a  reason  for  not 
curing  patients  of  acute  disease  may  be  due  to  the 
long  continued  action  of  a  stimulus  so  weak  that  were 
it  continued  but  a  short  time  it  would  make  no  per- 
ceptible influence  on  the  patient's  health.  It  is  to 
lessen  the  severity  of  acute  diseases  and  prevent  the 
development  of  those  that  are  chronic  in  character, 
that  the  child  should  be  examined  for  abnormal  con- 
ditions at  birth. 

Redundant  Foreskin. — Probably  the  most  com- 
mon of  these  in  male  children  is  the  adherent  and 
redundant  foreskin.  The  following  cases  are  given 
to  show  some  of  the  different  reflex  conditions  pro- 
duced by  it : 

The  first  case  showed  symptoms  of  an  imperfect 
gastric  digestion  during  the  first  few  months  after  its 
birth,  which  continued  until  cured  at  the  age  of  six 


REFLEXES.  65 

years.  During  the  second  summer  of  its  existence 
it  had  frequent  acute  attacks  of  gastro-intestinal  ca- 
tarrh. These  attacks  recurred  so  frequently  that  the 
child  was  taken  on  a  steamer  to  northern  Michigan. 
Some  little  improvement  was  wrought  by  the  change 
of  climate,  but  it  was  late  in  the  fall  before  it  was 
fairly  out  of  danger  of  these  serious  acute  manifes- 
tations of  the  disease.  The  stomach  remained  weak, 
imperfectly  doing  its  work,  aggravated  by  a  diet  not 
very  carefully  regulated  both  in  regard  to  quality  and 
quantity.  It  was  also  influenced  by  changes  of  tem- 
perature. Several  physicians,  myself  among  the 
number,  treated  the  patient  without  producing  any 
marked  improvement.  He  was  for  a  time  under  the 
professional  charge  of  a  specialist  for  diseases  of  the 
digestive  organs,  without  benefit.  Of  course,  acute 
exacerbations  subsided  with  or  without  medicine. 
When  he  was  six  years  old  I  was  asked  to  prescribe 
for  enuresis  that  troubled  him  day  as  well  as  night. 
Thinking  there  might  be  some  local  cause  of  this  an- 
noying trouble,  I  examined  genital  organs  and  found 
the  foreskin  adherent  to  one  side  of  the  glans  penis. 
This  was  corrected  in  less  than  five  minutes  with  my 
fingers.  He  had  no  further  trouble  in  retaining  the 
urine  and  he  made  marked  improvement  from  that 
time.  One  year  after  his  mother  reported  no  more 
trouble  with  the  digestive  organs. 

It  is  not  claimed,  of  course,  that  every  case  of 
enuresis,  any  more  than  every  case  of  indigestion,  is 
caused  by  the  condition  described  in  the  above  case. 

I  was  asked  to  examine  a  male  child  eighteen 
months  old,  an  idiot ;  the  parents  were  very  intelli- 
6 


66  PRESENT    STATUS    OF    PEDIATRICS. 

gent.  It  had  been  delivered  by  the  aid  of  instru- 
ments. No  evidence  of  injury  could  be  found.  The 
mother,  wiser  than  some  physician,  in  this  case  at 
least,  made  a  comparative  examination  between  her 
child  and  the  male  child  of  a  friend.  The  foreskins 
were  different.  The  mother  reasoned  that  as  her 
child  was  ill  and  the  friend's  well,  if  either  foreskin 
was  wrong  it  must  be  that  of  her  boy.  The  child 
was  circumcised  and  the  adhesions  between  the  glans 
penis  and  foreskin  broken  up.  The  child  was  well  in 
two  months.  There  was  marked  mental  improve- 
ment during  the  first  week  following  the  operation. 

The  following  are  cases  cured  by  operation  on  the 
foreskin,  reported  by  Sayre : 

Para. — "  Child  five  years  old,  knees  flexed  at  angle 
of  45  degrees,  paralysis  of  extensors,  pulse  weak; 
tenotomy  had  been  advised,  but  not  performed.  Two 
weeks  after  the  operation  child  walked  without  aid 
and  finally  made  a  complete  recovery. 

"Double  talipes  equino-variis  paralytica  in  child 
aged  three  years.  Had  been  under  treatment  be- 
tween two  and  three  years  in  a  public  institution  of 
New  York.  Greatly  improved  in  two  weeks  after  op- 
eration. 

"Paralysis  of  lower  extremities,  prolapsus  of  rec- 
tum, and  constipation.  Operation  June  2,  could  stand 
alone  June  4,  and  complete  recovery  at  the  end  of 
twelve  days. 

"Partial  atrophy  of  optic  nerve  in  man  aged  thirty- 
four  years,  eye  trouble  of  eight  years'  duration,  can 
only  read  large  print  and  then  but  few  minutes  to- 
gether.     Operation  restored  general  health  in  one 


REFLEXES. 


67 


month  and  enabled  the  patient  to  read  a  page  of  small 
print  without  any  unpleasant  result." 

Clitoris. — Dr.  Sayre  also  reports  cases  benefited  by 
correcting  troubles  of  the  clitoris.  One  child  whom 
he  treated  was  eight  years  old  and  had  never  been 
able  to  walk.  Two  months  after  operation  she  walked 
unaided  across  three  rooms. 

These  cases  are  given  to  call  attention  to  the  fact 
that  an  irritation  in  the  same  part  of  the  body  may 
produce  various  reflex  diseases  in  different  individu- 
als. It  should  also  be  remembered  that  the  stimulus 
that  results  in  great  functional  disturbance  in  a  single 
organ  in  each  case  may  in  others  diffuse  its  force  to 
many  organs,  thereby  slightly,  in  a  short  time,  im- 
pairing them  all,  with  no  very  clear  manifestations  of 
disease  in  any  one ;  but  by  undermining  the  recupera- 
tive power  the  individual  is  rendered  especially  sus- 
ceptible to  any  exciting  cause  of  disease  and  ultimately 
some  chronic  ailment  is  insidiously  developed. 

I  will  give  an  example  to  corroborate  the  last  state 
ment.  A  young  lady,  about  eighteen  years  of  age, 
had  for  many  years  of  her  life  been  subject  to  severe 
attacks  of  headache,  the  attacks  gradually  increasing 
in  frequency.  She  was  pale,  listless  and  tired,  with 
a  poor  appetite.  The  menses  wxre  regular  and  nor- 
mal. She  had  had  several  acute  diseases,  one  of 
which  was  typhoid  fever.  She  had  not  since  a  child 
been  considered  a  very  strong  girl  by  her  parents. 
Of  course,  she  had  sought  relief  from  physicians  and 
taken  much  medicine  without  any  apparent  benefit. 
I  was  no  more  successful  with  drugs  than  those  who 
had  previously  prescribed  for  her.     Finally,  I  did  what 


68  PRESENT    STATUS    OF    PEDIATRICS. 

should  have  been  done  when  she  was  a  child,  exam- 
ined the  clitoris,  and  found  the  hood  adherent.  The 
adhesions  were  loosened  and  the  patient  gradually 
gained  strength  and  recovered  from  the  headaches. 
No  drug,  no  matter  how  carefully  selected,  would  cure 
such  a  case  and  it  was  unwise,  unscientific,  to  admin- 
ister drugs  to  her ;  and  yet  I  have  no  doubt  that  many 
chronic  cases  called  nervous  prostration,  general  de- 
bility, or  some  other  of  the  indefinite  terms  that  phy- 
sicians have  taught  the  laity  to  accept  as  expressing 
something  scientific,  are  due  to  a  reflex  irritation  per- 
haps no  greater  than  the  one  in  the  case  just  described, 
and  which  may  be  produced  by  congenital  deformi- 
ties. 

These  cases  have  been  given  to  show  not  only  that 
an  abnormal  stimulus  may  cause  reflex  disease,  but 
also  that  the  same  stimulus  produces  different  diseases 
in  different  individuals.  Notice  in  these  cases  that 
the  irritation  caused  by  the  foreskin  resulted  in  chronic 
impairment  of  the  stomach  digestion  in  one  subject; 
idiocy  in  another ;  in  a  third  paralysis  of  the  extensors 
of  the  leg;  a  fourth  talipes  equinus;  a  fifth  paralysis 
of  the  lower  extremities,  constipation,  and  protrusion 
of  the  rectum ;  and  in  the  sixth,  after  many  years,  se- 
rious impairment  of  vision.  In  other  cases,  with  a  less 
degree  of  irritation,  or  a  greater  amount  of  constitu- 
tional strength  possessed  by  the  patient,  there  will  be 
produced  less  marked  symptoms  of  disease,  but  none 
the  less  surely  will  the  various  functions  of  the  child 
organism  be  impaired  and  predisposed  to  disease  con- 
ditions which  are  entirely  too  common  and  fatal  in 
childhood.     Often  Nature  corrects  the  trouble ;  if  she 


REFLEXES.  69 

does  not  the  adult  is  invariably  an  invalid ;  but  even 
when  Nature  removes  the  cause  of  irritation  serious 
harm  has  been  done  to  the  child.  It  is  not  creditable 
to  medicine  and  surgery  that  there  are  thousands  of 
people  in  all  countries  where  medicine  is  taught  suf- 
fering from  chronic  disease.  These  very  often  may 
be  traced  back  to  childhood  and  to  causes  that  were 
removable  at  that  age. 

Rectum. — Dr.  Pratt  has  discovered  and  taught, 
and  his  teaching  has  been  corroborated  by  all  who 
have  made  clinical  use  of  it,  that  the  lower  part 
of  the  rectum  is  abundantly  supplied  with  nerves, 
which  act  as  afferent  fibers  to  a  reflex  arc,  and  that 
abnormal  conditions  of  this  part  of  the  bowel  are  pro- 
ductive of  many  reflex  disorders.  He  has  found  that 
dilatation  of  the  sphincter  ani  is  a  powerful  means  of 
resuscitation  and  that  it  is  the  most  reliable  method 
known  for  starting  respiration  in  still-born  children. 
Since  the  originator  of  this  method  introduced  it  to 
the  profession  it  has  come  into  general  use  as  a  means 
of  resuscitation. 

A  regular  physician  writes  as  follows :  ' '  The  meth- 
ods of  resuscitation  usually  employed  are  open  to 
various  objections.  They  all  require  time,  which  is 
the  all-important  element  in  these  cases.  Some  of 
them  compel  the  use  of  unseemly  and  disagreeable 
measures,  others  of  more  or  less  cumbersome  and  in- 
convenient means,  and  all  distract  the  physician's  at- 
tention from  the  mother,  who,  at  this  time  peculiarly 
and  by  every  right,  is  entitled  to  that  care  and  con- 
sideration which  only  the  closest  and  most  constant 
attention  can  secure  to  her.     These  are  the  general 


7©  PRESENT    STATUS    OF    PEDIATRICS. 

objections — not  to  specify  the  many  inhuman  and 
grotesque  impositions,  such  as  spanking  the  baby, 
alternate  boiling  and  freezing  with  hot  and  cold  baths, 
mouth  to  mouth  insufflation,  artificial  respiration,  and 
the  various  other  scientific  indignities  which  are  daily 
being  perpetrated  upon  helpless  innocence." 

Of  course  dilatation  of  these  sphincters  must  af- 
fect the  respiration  by  means  of  reflex  influence.  If 
relaxing  the  anal  muscles  to  an  extreme  degree  as- 
sists respiration,  then  their  abnormal  contraction, 
which  may  be  caused  by  the  presence  of  a  local  irri- 
tant, will  reflexly  hinder  respiration  or  compel  the 
respiratory  centers  to  expend  an  undue  amount  of 
energy  to  regulate  these  processes.  In  either  case 
disease  must  result,  the  vital  force  be  diminished  and 
a  chronic  disease  slowly  developed,  or  an  acute  one 
rendered  less  amenable  to  treatment. 

In  General. — It  is  not  my  purpose  to  discuss  rec- 
tal pathology  in  connection  with  reflexes,  but  I  do 
wish  to  assert  that  it  is  the  cause  of  many  functional 
derangements  which  are  frequently  followed  by  or- 
ganic changes.  Patients  do  not  understand  why  a 
slight  irritation  of  the  glans  penis ^  the  clitoris,  the 
rectum,  or  the  nares  will  produce  trouble  remote 
from  its  direct  action,  nor  why  the  ill-effects  are 
more  pronounced  than  if  a  greater  stimulus  were 
applied  to  the  nerve  nearer  its  central  termination. 
The  first  is  understood  by  a  knowledge  of  the  fact 
that  a  stimulus  may  be  so  weak  and  of  such  short 
duration  that  there  will  be  no  discharge  of  a  reflex 
act;  but  if  it  be  continued  it  will  produce  the  act. 
The  second   because   stimi^lation   of   the    peripheral 


REFLEXES. 


7i 


end  of  the  afferent  nerve  more  readily  and  thor- 
oughly causes  the  discharge  of  a  reflex  act  than  stim- 
ulation in  its  course.  For  example,  a  slight  continued 
tickling  of  the  skin  over  the  knee  will  in  many  indi- 
viduals cause  uncontrollable  and  hysterical  laughter, 
while  stimulus  applied  to  the  main  nerve,  from  which 
this  region  is  supplied,  causes  local  pain  only. 

One  of  the  common  derangements  of  early  child- 
hood is  constipation.  The  laxatives  of  the  regular 
school,  the  homoeopathic  remedies,  and  a  diet  care- 
fully selected  from  the  many  foods  at  the  command  of 
the  physician  all  fail  too  often  to  cure  this  condition. 
Very  frequently,  after  other  means  have  been  faithfully 
tried,  the  trouble  has  been  overcome  by  dilatation 
of  the  anal  sphincters.  The  same  cause  that  will  in 
one  subject  produce  constipation  will  in  another  cause 
diarrhoea.  I  have  seen  the  former  cured  by  relieving 
an  anal  fissure ;  in  another  case  the  latter  was  cured 
by  removing  the  same  cause.  Recently  a  case  came 
under  observation  which  had  had  diarrhoea  for  a  year. 
The  patient  had  from  two  to  a  dozen  loose  stools  in 
twenty-four  hours.  Colicky  pains  preceded  defeca- 
tion, with  rumbling  of  gas  in  the  abdomen.  There 
were  no  sharp  nor  severe  pains  in  the  anus,  only  a  slight 
smarting  or  burning  sensation, — nothing  that  resem- 
bled the  usual  description  of  the  pains  incident  to  a 
fissure ;  but  nevertheless  a  large  one  existed.  Local 
anaesthesia  was  produced  by  a  solution  of  cocaine,  then 
95  per  cent  carbolic  acid  applied  to  the  fissure ;  the 
stools  became  normal  in  one  week  after  treatment.  It 
should  not  seem  strange  to  the  members  of  our  school 
of  medicine  that  different  conditions,  or  rather  oppo- 


72  PRESENT    STATUS    OF    PEDIATRICS. 

site  manifestations  of  the  same  condition,  respond  to 
the  same  remedy.  It  may  be  explained  by  the  dif- 
ference in  the  discharging  power  of  the  center  of  the 
reflex  arc. 

While  calling  attention  in  a  general  way  to  the  im- 
portant influence  that  stimuli  may  exert  in  a  reflex 
manner  on  remote  organs  of  the  body,  it  is  in  nowise 
intended  that  other  causes  of  disease  should  be  ig- 
nored, for  it  would  be  foolish  to  treat  a  disease  due  to 
central  conditions  alone  as  a  reflex  disorder.  I  believe, 
however,  that  many  chronic  pathological  conditions 
which  seem  to  be  primary  are  due  to  long  continued 
impairment  of  important  processes  of  the  body  due  to 
reflex  influences  that  permit  the  development  of  these 
diseases  which  become  independent  and  do  not  dis- 
appear after  the  exciting  cause  is  removed.  The  im- 
portance of  a  thorough  examination  of  a  child  cannot 
be  overestimated.  All  abnormal  stimuli  should  be 
corrected  if  the  danger  incident  to  child  life  be  re- 
duced to  a  minimum,  and  the  increase  in  the  great 
army  of  chronic  sufferers  be  stopped. 


DISEASES   OF    THE   BRAIN.  73 


CHAPTER  IV. 


DISEASES    OF   THE    BRAIN,   INCLUDING 
CEREBRO-SPINAL  MENINGITIS. 

BY  MARTIN  DESCHERE,   M.  D. ,   PROFESSOR  OF    P.^DOLOGY,   NEW  YORK 
HOMCEOPATHIC  MEDICAL  COLLEGE  AND  HOSPITAL,   NEW  YORK. 

SIMPLE  MENINGITIS.— Etiology.— The  simple 
non-tubercular  inflammation  of  the  pia  mater  is  most 
generally  localized  at  the  convexity  of  the  brain.  It 
rarely  occurs  primarily  and  is  most  frequently  in- 
duced by  other  diseases,  as,  for  instance,  by  caries  of 
the  petrous  portion  in  otitis  media,  facial  erysipelas, 
eczema  on  the  head,  affections  of  the  nose,  and  py- 
aemic  or  septic  processes,  the  latter  especially  in  the 
new-born.  It  also  occurs  after  operations  and  in- 
juries of  the  head,  and  follows  various  acute  infec- 
tious diseases,  mostly  pneumonia,  scarlatina,  measles, 
or  endocarditis,  nephritis,  and  peritonitis. 

Morbid  Anatomy. — Anatomically  we  find  a  yellow 
or  greenish-yellow  fibrinous  exudation  in  the  meshes 
of  the  pia  mater,  which  often  covers  a  large  area, 
especially  on  the  convexity.  The  blood  vessels  are 
markedly  injected,  and  the  membrane  shows  serous 
infiltration.  The  substance  of  the  brain  underlying 
the  affected  parts  may  also  show  signs  of  inflamma- 


74  PRESENT    STATUS    OF    PEDIATRICS. 

tion,  which  may  extend  to  the  base,  the  medulla 
oblongata,  and  continues  down  into  the  spinal  cord. 
If  the  origin  has  been  traumatic,  the  dura  mater  will 
also  participate  and  the  sinus  will  appear  hyperaemic. 
Purulent  infiltration  has  been  observed  along  the 
course  of  the  larger  vessels  of  the  pia  mater,  and  ad- 
hesions to  the  brain  and  arachnoid  are  found  in  many 
places ;  the  ventricles  are  generally  found  empty. 

Symptomatology. — The  disease  frequently  begins 
suddenly ;  drowsiness,  headache,  vertigo,  or  vomiting 
rarely  precede  it.  Most  generally  we  find  a  quick  rise 
of  temperature,  which  remains  high  throughout,  fre- 
quently above  104,  great  restlessness,  grinding  of  the 
teeth,  then  vomiting,  with  severe  convulsions,  set  in. 
These  symptoms  are  accompanied  by  sharp  cries  while 
the  child  is  entirely  unconscious,  and  no  external 
impressions  will  be  able  to  rouse  the  child  from  this 
comatose  state.  This  coma  may  be  interrupted  at 
intervals  by  delirium  or  spasms.  The  pupils  are 
mostly  contracted,  sometimes  irregular,  and  the  eye- 
ball is  rolled  upwards,  sometimes  oscillating.  The 
head  and  face  are  hot,  and  the  child  grasps  his  head 
with  his  hands  and  throws  himself  about.  The /<?;/- 
tajielle  protrudes,  showing  strong  pulsations.  Pulse 
and  respiration  are  accelerated  in  the  beginning,  be- 
coming slower  later  on.  The  bowels  are  constipated 
whilst  the  abdomen  is  soft  and  often  retracted.  In 
cases  ending  fatally  the  convulsions  repeat  more  and 
more  rapidly,  being  followed  by  paralysis  of  one  or 
more  extremities  during  increasing  coma  and  enlarg- 
ing pupils.  Shortly  before  death,  which  may  occur 
within  one  or  two  days,  the  pulse  will  become  very 


DISEASES    OF    THE    BRAIN.  75 

rapid.  Sometimes,  when  the  disease  develops  more 
slowly,  we  will  have  incipient  symptoms,  consisting 
of  irritability,  peevishness,  or  an  apathetic  state  of  the 
mind,  restless  sleep,  and  spontaneous  vomiting ;  tre- 
mor and  light  twitchings  of  the  extremities  are  then 
observed  during  gradually  increasing  drowsiness,  and 
in  this  condition  older  children  complain  of  continuous 
headache.  Suddenly  a  chill  followed  by  high  fever, 
delirium,  and  convulsions  set  in,  w^hich  are  then  suc- 
ceeded by  coma  and  the  symptoms  as  described  above. 
If  death  does  not  occur  at  such  a  climax,  we  will  notice 
a  gradual  decrease  of  the  symptoms,  and  the  disease 
may  take  a  protracted  course  lasting  for  several  weeks. 
The  sensorium  remains  dull  during  all  this  time,  the 
fever  keeps  on,  paralysis  or  contraction  of  single  sets 
of  muscles,  as  well  as  isolated  spasms,  appear,  during 
which  the  patient  may  succumb  under  sudden  coma 
and  general  collapse.  During  this  protracted  course 
emaciation  becomes  excessive. 

If  the  meningitis  is  marked  by  the  disease  causing 
it,  all  of  these  symptoms  are  not  plainly  apparent. 
Sometimes  especially  the  convulsions  are  wanting,  or 
they  are  substituted  by  contractions,  or  they  may  just 
appear  toward  the  end.  High  fever  will  likewise  be 
absent,  and  the  patient  will  recover  from  the  sopor- 
ous condition ;  but  delirium,  vomiting,  and  the  con- 
traction of  the  pupils  will  almost  always  be  observed. 

The  duration  of  the  disease  is,  as  a  rule,  but  a 
few  days,  rarely  longer  than  a  week ;  young  infants 
may  succumb  in  as  many  hours ;  it  rarely  lasts  from 
two  to  three  weeks.  According  to  old  school  authori- 
ties, the  usual  termination  is  death,  and  in  the  cases 


76  PRESENT    STATUS    OF    PEDIATRICS. 

reported  cured  in  our  literature,  it  has  been  preferred 
to  doubt  the  diagnosis  rather  than  to  admit  success, 
for  that  is  the  easiest  way  of  ignoring  the  superior 
efficacy  of  horaoeopathy.  Children  who  survive  may 
show  serious  affections  remaining  after  meningitis, 
the  same  as  we  find  in  the  cerebro-spinal  form. 

Diag'nosis. — It  is  often  difficult  to  distinguish  men- 
ingitis at  a  time  when  it  enters  as  a  complication  upon 
another  disease,  especially  in  such  cases  where  its  de- 
velopment is  slow  and  where  all  the  prominent  symp- 
toms are  not  present.  The  further  course  of  the  case 
will  then  clear  the  diagnosis.  The  differentiation  from 
typhoid  consists  in  the  late  appearance  of  nervous 
symptoms  in  the  latter,  the  more  typical  fever  curve, 
the  roseola,  and  the  enlargement  of  the  spleen.  We 
may  consider  Kering's  symptom,  consisting  in  the  in- 
voluntary forced  flexion  of  the  knee  joint,  which  sets 
in  immediately  when  the  child  rises  in  bed,  or  when 
lying  on  its  side  on  flexing  the  thigh  upon  the  abdo- 
men, as  an  important  diagnostic  point,  although  not 
a  pathognomonic  one,  which  distinguishes  simple 
meningitis  from  other  affections  of  the  brain.  The 
prognosis  in  undoubted  cases  is  rather  unfavorable. 

From  what  has  been  said  regarding  the  course  and 
diagnosis  of  meningitis,  it  will  be  apparent  that  much 
of  the  physician's  success  depends  upon  the  early  rec- 
ognition of  the  true  character  of  the  disease. 

Treatment. — The  homoeopathist,  however,  follow- 
ing closely  the  picture  his  patient  presents  in  its 
minutest  details,  will  not  long  be  puzzled  as  to  the 
selection  of  an  appropriate  remedy,  even  before  he 
has  decided  upon  the  distinct  variety  of  the  affection 


DISEASES   OF    THE    BRAIN.  77 

under  treatment ;  but  he  will  make  his  diagnosis  as 
speedily  as  he  conscientiously  can.  Fortunately  the 
homoeopathic  remedy  has  to  correspond  simply  to  the 
symptoms  present  in  the  case,  for  these  are  the  only 
tangible  means  to  arrive  at  a  scientific  medicinal 
treatment.  Thus  no  time  will  be  lost,  nor  injury 
done  by  injudicious  or  unsuitable  means,  and  life  is 
frequently  saved  by  such  prompt  interference,  which 
will  always  be  correct  as  long  as  the  physician  abides 
firmly  by  his  law  of  cure.  External  application  of 
the  ice  bag  I  consider  worse  than  useless,  for  besides 
the  restlessness  of  the  patient  making  it  impracticable, 
the  contraction  of  the  external  blood  vessels  by  cold 
helps  to  increase  the  tension  inside  the  cranium.  It 
is  wise,  however,  to  keep  the  patient  in  a  cool  room, 
in  perfect  quiet,  and  under  subdued  light,  on  account 
of  the  hyperaesthesia  of  the  senses.  In  advanced 
cases,  when  increasing  stupor  or  any  paralysis  is  ob- 
served, it  is  important  to  see  to  the  patient's  nourish- 
ment, and  to  administer  per  rectum,  if  swallowing 
has  become  impossible. 

The  condition  of  the  ears  should  always  be  carefully 
ascertained  from  the  beginning,  and  if  an  otitis  has 
shortly  preceded  the  meningitis,  or  if  a  bulging  of  the 
tympanum  indicates  the  possibility  of  retained  pus, 
free  evacuation  should  be  secured  by  proper  means. 

Of  the  remedies  needed  in  simple  meningitis,  bella- 
donna^ apis^  gelsemium^  helleborus,  ciciita^  cina^  opiiim^ 
stramonium^  veratruin  viride^  and  zincum  stand  fore- 
most. Aconitum^  apis^  belladon?ia^  bryo7iia^  ctiprum, 
f err  urn.  phosphor  icum,  hepar^  mercurms  solubilis,  pidsa- 
tilla,  and  sulphur  are  valuable  when  meningitis  occurs 


78  PRESENT    STATUS    OF    PEDIATRICS. 

during  or  after  the  eruptive  fevers,  also  during  or  after 
otitis  media  or  mastoid  disease.  Arjiica^  glonoine^ 
hepar,  hypericum^  in  traumatic  cases  or  after  long 
exposure  to  heat.  ^tJmsa^  anacardium^  cantharis, 
ciniicifuga^  digitalis^  mix  vomica^  and  a  few  others  will 
be  indispensable  under  suitable  conditions. 

TUBERCULAR  OR  BASILAR  MENINGITIS.— 
Pathology. — This  form  of  meningitis,  which  formerly 
was  wrongly  designated  as  acute  hydrocephalus,  con- 
sists in  the  appearance  of  miliary  tubercles  in  the  me- 
ninges, plus  an  inflammation  of  the  pia  mater  which  is 
localized  at  the  base  of  the  brain,  and  is  usually  ac- 
companied by  an  acute  exudation  into  the  ventricles. 
The  pathogenesis  of  this  condition  is  identical  with 
that  of  general  tuberculosis,  and  appears  frequently 
secondary  to  systemic  tubercular  affection.  Only  in 
very  isolated  cases  tubercles  have  been  found  in  the 
meninges  primarily,  and  were  then  limited  there. 

The  most  frequent  starting  points  for  this  form  of 
meningitis  during  childhood  are,  therefore,  pulmo- 
nary tuberculosis,  caseation  of  the  bronchial  or  cervical 
glands,  and  conditions  especially  predisposing  for  this 
disease,  most  prominently  measles  and  whooping- 
cough.  Occasionally  we  find  tubercular  infiltration 
of  various  lymphatic  glands  and  tubercular  inflamma- 
tion of  the  bones  and  joints  to  form  the  centers  of  in- 
fection. Tubercular  meningitis  is  rather  frequent  in 
children,  attacking  most  particularly  scrofulous  sub- 
jects and  those  hereditarily  inclined.  Boys  at  from 
one  to  four  years  of  age  are  the  most  frequent  victims, 
while  the  frequency  decreases  as  the  age  advances. 
The  exciting  cause  in  such  cases  will  often  be  an  in- 


DISEASES    OF    THE    BRAIN.  79 

jury  to  the  head  or  mental  strain.  In  many  tuber- 
cular families  several,  perhaps  all  the  children  may 
suffer  from  meningitis ;  in  others,  the  first  born  only. 
Symptomatolog'y. — Most  cases  are  preceded  by  ill 
health  for  several  months,  perhaps  succeeding  an 
attack  of  whooping-cough  or  measles,  during  which 
time  the  child  has  markedly  wasted.  Indigestion, 
but  more  frequently  cough  with  fever  and  nightly 
exacerbation  will  sometimes  arouse  our  attention, 
especially  if  we  find  glandular  enlargement,  and  a 
tubercular  family  history.  Again,  brain  symptoms 
will  precede  the  actual  attack  of  meningitis  for  weeks 
and  consist  in  headache,  squinting,  staggering,  ex- 
treme irritability,  great  change  of  disposition,  and 
loss  of  control  over  the  sphincters;  this  will  gen- 
erally be  accompanied  by  drowsiness,  and  transi- 
tory fever  with  thirst.  All  these  symptoms  may 
occur  in  groups  or  single,  and  may  again  disap- 
pear, so  that  but  little  importance  is  attached  to 
them.  But  soon  more  definite  signs  mark  the  onset 
of  the  disease,  that  of  brahi  excitement^  in  which 
vomiting  is  most  prominent,  frequently  continuing 
for  several  days,  notwithstanding  careful  diet.  The 
tongue  remains  clean,  but  there  is  much  nausea  and 
retching;  the  vomiting  is  generally  erratic,  coming 
and  going  without  apparent  cause.  Characteristic 
cerebral  symptoms  may  yet  be  absent.  Constipation 
is  the  rule ;  the  abdomen  becomes  flabby  and  later  re- 
tracted. Soon  headache,  then  giddiness  set  in,  indi- 
cated in  young  children  by  their  grasping  the  head, 
moaning  and  whining,  with  intolerance  of  strong  light 
and  noise.     The  child  is  now  feverish  and  extremely 


8o  PRESENT-  STATUS    OF    PEDIATRICS. 

irritable,  it  will  not  be  disturbed  by  anybody,  but 
clings  to  its  mother  for  attention.  In  other  cases,  the 
headache,  staggering  gait,  and  dizziness  may  be  there 
from  the  start,  while  vomiting  is  less  prominent. 
Sleep  is  disturbed  by  vivid  dreams  and  grinding  of 
the  teeth,  out  of  which  the  child  awakens  with  a  pierc- 
ing cry,  known  as  the  ' '  crie  Jiydrocephaliqiie. "  It  pre- 
fers to  lie  quiet  and  undisturbed,  and  will  not  be 
amused  or  play  with  its  toys.  It  will  also  complain 
of  pain  in  the  ear,  throat,  abdomen,  or  extremities. 
In  young  infants  the  fontanelle  will  bulge.  Even  at 
this  early  period  of  the  disease  the  pulse  begins  to 
become  irregular,  varying  in  frequency,  becoming 
gradually  slower,  but  increasing  again  later  on.  This 
does  not  correspond  with  the  temperature  curve,  which 
is  very  uncertain  throughout  the  disease,  jumping 
three  or  four  degrees  within  twenty-four  hours,  gen- 
erally lasting  longer  on  a  high  mark,  however.  Res- 
piration also  changes  in  regularity,  being  alternately 
superficial  and  deep,  sighing.  In  the  beginning  the 
patient  will  give  short  answ^ers  to  questions,  but  he 
soon  becomes  more  apathetic  and  indifferent  even  to 
bodily  examinations.  A  soporous  condition  super- 
venes, interrupted  by  periodical  restlessness,  delirium, 
and  piercing  cries.  At  the  same  time  we  observe 
photophobia  and  sensitiveness  to  sound  and  slight 
touch,  also  automatic  sucking  and  chewing  motions. 
Many  children  bite  or  snap  and  make  pendular  move- 
ments with  one  or  another  extremity ;  some  bore  their 
nose  incessantly,  others  grasp  about  the  lower  abdo- 
men and  genitals.  Twitchings,  muscular  contractions 
of  the  neck  and  back,  or  convulsions  will  now  appear. 


DISEASES    OF    THE    BRAIN.  8l 

which,  when  general,  may  bring  about  a  fatal  result, 
especially  in  infants.  Paralysis  involves  the  muscles 
of  the  eyes,  lips,  face,  or  limbs  of  one  side.  Rolling 
of  the  head  from  side  to  side  is  a  frequent  symptom ; 
and  in  some  cases  the  contraction  of  the  neck  is  so 
extreme  at  the  same  time,  that  the  back  of  the  head 
touches  the  spine,  amounting  to  complete  opis- 
thotonos. Consciousness  continually  diminishes,  the 
patient  can  only  be  roused  by  loud  calling,  and  will  then 
take  a  little  nourishment,  which  is  otherwise  refused. 
He  mostly  lies  quiet  with  eyes  half  closed,  the  bulbi 
rolled  upwards,  the  conjunctivae  injected ;  at  the  same 
time  strabismus,  with  alternating  contraction  and  di- 
latation of  the  pupils,  is  common.  There  is  apt  to  be 
incontinence  of  the  urine  and  stool.  Gradually  this 
state  changes  into  one  of  complete  coma,  from  which 
the  child  cannot  be  roused.  The  conjunctivae  become 
insensible,  the  pupils  more  dilated.  This  condition 
admits  an  examination  of  the  optic  discs,  the  edges  of 
which  appear  blurred  and  indistinct  from  the  presence 
of  swelling;  the  veins  are  distended  and  tortuous. 
Should  general  tuberculosis  be  present,  this  may  also 
be  detected  in  the  choroid.  The  pulse  now  becomes 
permanently  accelerated  and  regular,  but  weaker  and 
often  hardly  perceptible ;  and  the  respiration  presents 
more  clearly  the  Cheyne-Stokes  character.  The  face 
is  pale,  the  extremities  are  cool  and  clammy,  while 
the  temperature  in  the  rectum  is  very  high  or  subnor- 
mal. The  body  appears  much  emaciated,  the  skin 
dry  and  harsh.  Excessive  secretion  takes  place  from 
the  conjunctivae,  so  that  the  eyes  become  covered  with 
a  veil  of  mucus  or  pus.     The  tongue  presents  a  thick 

7 


82  l^RESENT    STATUS    OF    PEDIATRICS. 

brown  coating,  there  are  sordes  on  the  teeth,  and  black 
crusts  on  the  lips.  This  state  may  last  for  several 
days,  even  a  week,  being  interrupted  by  convulsions, 
tremor,  opening  and  turning  the  eyes ;  then  gradually 
passing  into  a  moribund  condition. 

A  typical  picture  of  the  disease  is  by  no  means  al- 
ways found,  especially  in  young  infants,  in  which  the 
characteristic  symptoms  may  be  absent  and  no  diag- 
nosis is  made  until  the  child  is  comatose  or  actually 
dying.  The  division  into  stages,  as  was  formerly  the 
custom,  is  therefore  not  practical.  There  may  have 
been  vomiting  of  food  without  any  further  indication 
of  illness,  then  some  rigidity  of  single  groups  of  mus- 
cles will  set  in,  and  gradually  sopor  and  coma  follow. 
In  other  cases,  nervous  symptoms  supen^ene.  The 
state  of  the  fontanelle  will  be  of  some  help  in  the 
diagnosis,  for  it  will  always  be  full  and  bulging,  and 
later  on  the  veins  on  the  forehead  will  swell  more 
prominently. 

The  duration  of  the  disease  varies  greatly  accord- 
ing to  the  multiplicity  of  the  symptoms,  a  combina- 
tion with  other  diseases,  and  the  age  of  the  patient. 
Most  cases  die  within  three  or  four  weeks,  but  con- 
vulsions may  prove  fatal  during  the  first  week.  The 
course  is  short  when  occurring  in  addition  to  pulmo- 
nary tuberculosis ;  it  is  also  short  in  young  infants 
when  beginning  with  convulsions  which  rapidly  pass 
into  coma. 

Diagnosis. — Cases  which  develop  gradually,  and 
where  tubercular  affections  are  present  in  remote 
organs,  are  not  difficult  to  diagnose.  Ophthalmoscopic 
examination  will  lead  to  a  positive  result  if  choroid- 


DISEASES    OF    THE    BRAIN.  83 

tuberculosis  can  be  demonstrated,  but  a  negative  re- 
sult cannot  be  relied  upon.  Marked  gastro-intestinal 
symptoms  will  obscure  the  diagnosis,  especially  in 
well  nourished  children.  The  same  is  true  with 
reference  to  simple  meningitis,  which  is  sometimes 
difficult  to  distinguish  from  the  tubercular  form ;  the 
rapid  onset  with  continuous  high  fever  speak  for  the 
former,  a  slow  development  and  less  intensity  of  the 
premonitory  symptoms  for  the  latter.  Cerebro-spinal 
meningitis  must  be  thought  of  when  a  number  of 
cases  appear  epidemically,  an  eruption  will  give  ad- 
ditional evidence.  The  temperature  curve  and  the 
character  of  the  pulse  will  help  to  differentiate 
typhoid  fever. 

The  prognosis  in  true  tubercular  meningitis  is  al- 
ways grave,  though  not  hopeless,  but  even  if  appar- 
ent improvement  sets  in,  and  if  such  cases  recover 
from  the  meningeal  affection,  the  tubercular  process 
will  lead  to  a  fatal  termination  sooner  or  later. 

Treatment. — In  addition  to  the  care  of  the  patient 
during  an  attack  of  meningitis,  as  given  above  under 
the  simple  form,  we  may  speak  of  2l  prophylactic  treat- 
ine7it  in  tubercular  meningitis.  This  should  be  much 
the  same  as  that  of  general  tuberculosis.  Children 
with  a  tubercular  diathesis  require  the  utmost  care 
throughout.  Their  systems  should  be  invigorated  by 
out-of-door  life,  they  should  pass  their  summers  at 
the  sea-shore  or  at  the  mountains,  and  should  be  care- 
fully protected  from  changes  of  weather  at  all  seasons. 
Pure  milk  and  cream  will  be  the  best  basis  for  their 
food.  All  mental  excitement  must  be  strictly  pro- 
hibited, and  they  should  be  kept  from  even  the  sim- 


84  PRESENT    STATUS    OF    PEDIATRICS. 

plest  kind  of  book  learning.  Arsenicuin  iodatiini^ 
baryta  carbonica^  baryta  iodata^  calcarea  carbonica^ 
calcarea  iodata^  calcarea  pJwspJiorica^  silicea^  sulphur^ 
psoriniun^  ttiberculin^  according  to  constitutional  in- 
dications, will  greatly  aid  to  improve  the  child's 
health  and  thus  tend  to  avoid  the  possible  outbreak 
of  the  disease.  For  the  treatment  of  tubercular  men- 
ingitis the  same  remedies  as  in  the  simple  form  will 
prove  efficacious.  Besides  those  we  may  select  from 
the  following:  Apocynum  cannabimnn^  argentuni  7ii- 
iricuni^  arternisia  vulgaris^  calcarea  carbonica^  calca- 
rea pJwsphorica^  iodium^  iodoform^  kali  iodata,  sp07t- 
gia^  sqjiilla^  tabacuin^  veratriun  album. 

CEREBRO-SPINAL  MENINGITIS.— This  affection 
is  also  known  by  the  names  of  cerebro-spinal  fever, 
epidemic  cerebro-spinal  meningitis,  spotted  fever,  etc. 
It  generally  occurs  epidemically,  sometimes  sporadic 
■cases  are  observed,  and  in  large  cities  it  has  become 
•endemic.  The  contagious  nature  is  but  feebly  ex- 
pressed. A  few  instances  have  been  recorded  where 
direct  infection  could  be  traced  absolutely.  We  will, 
therefore,  consider  it  an  acute  infectious  disease  gen- 
erally epidemic,  localized  in  the  pia  mater  and  arach- 
noid of  the  brain  and  spinal  cord.  It  chiefly  attacks 
children  up  to  five  years  of  age,  less  frequently  older 
ones  to  about  the  age  of  puberty.  After  thirty  years 
of  age  it  has  not  been  observed  except  in  isolated 
cases.  Males  are  more  frequently  subjected  than 
females. 

Epidemics  occur  especially  during  winter  and 
spring;  improper  hygienic  surroundings,  damp  and 
crowded  dwellings  being  the  most  frequent  breeding 


DISEASES    OF    THE    BRAIN.  85 

places.  Considering  the  nature  of  the  contagion  the 
Fraenke*l-Weichselbaum  coccus,  which  is  identical 
with  the  pneumo-coccus,  is  generally  accepted  as  the 
cause,  especially  as  it  has  been  found  by  many  com- 
petent observers  in  the  exudation  of  this  form  of 
meningitis,  and  experimental  meningitis  and  encepha- 
litis have  been  produced  by  the  pneumo-coccus.  The 
entrances  for  these  cocci  are  most  probably  the  nose, 
the  frontal  sinuses,  and  the  middle  ear.  But  why  it 
pleases  this  micro-organism  to  sometimes  produce 
pneumonia  and  sometimes  an  epidemic  of  cerebro- 
spinal meningitis  remains  still  a  mystery  which  it  will 
not  be  difficult  to  solve  for  the  ever  ready  bacteriolo- 
gist. 

Anatomically  we  find  acute  inflammation  of  the 
pia  mater  and  the  arachnoid,  with  sero-fibrinous  or 
purulent  exudations.  These  are  especially  found  in 
the  arachnoid  spaces,  and  abundantly  at  the  base  of 
the  brain,  also  on  the  convexity  in  the  fissures  between 
the  convolutions,  and  upon  the  spinal  cord  mostly  on 
its  posterior  surface.  Adhesions  are  formed  between 
the  upper  layers  of  the  brain  and  spinal  cord  and  their 
pia  mater.  The  substance  of  these  tissues  always 
shows  inflammatory  infiltration,  with  hyperaemia  of 
the  deep  blood  vessels.  The  ventricles  of  the  brain 
and  the  spinal  canal  appear  enlarged  and  filled  with 
a  turbid,  serous,  or  purulent  fluid.  We  also  find 
changes  in  organs  presenting  complications,  most  fre- 
quently in  the  lungs  and  kidneys ;  more  rarely  do  we 
find  suppurative  affections  of  the  eye  and  middle  ear. 

Incubation  and  Symptomatolog'y.— The  period 
of  incubation  is  but  short,  not  exceeding  five  days. 


86  PRESENT    STATUS    OF    PEDIATRICS. 

The  commencement  of  the  disease  is  preceded  by  a 
few  prodromal  symptoms,  consisting  of  general  ma- 
laise, pains  in  the  head  and  extremities,  loss  of  ap- 
petite, and  pronounced  restlessness.  But  the  attack 
may  be^n  suddenly  with  vomiting  and  convulsions, 
instead  of  w^hich  older  children  complain  of  chills, 
which  are  followed  by  intense  headache,  staring  look, 
with  contracted  pupils,  and  stiffness  of  the  neck  and 
back.  These  symptoms  are  followed  by  drowsiness 
or  complete  loss  of  consciousness ;  the  restlessness  is 
greatly  increased  and  accompanied  by  loud  piercing 
cries,  tonic  spasms  or  tremors,  and  an  extraordinary 
hyperaesthesia  of  the  skin.  The  child  lies  with  its 
head  drawn  backwards  by  contractions  of  the  muscles 
of  the  neck ;  these  as  well  as  the  w^hole  back  are  ex- 
tremely sensitive  to  pressure  or  even  touch.  The 
pulse  is  sometimes  slow,  but  generally  accelerated; 
respiration  shows  increased  frequency.  Constipation 
is  the  rule,  and  the  spleen  is  often  swollen.  The 
temperature  rises  from  the  start,  but  shows  great 
and  constant  fluctuations  during  the  duration  of  the 
disease.  The  further  development  of  cerebro-spinal 
meningitis,  after  these  first  symptoms  have  made  their 
appearance,  varies  greatly.  In  most  cases  we  have,  in 
addition  to  the  symptoms  mentioned,  tetanic  spasms, 
followed  by  deep  coma,  during  which  the  respiration  is 
sighing,  irregular,  sometimes  presenting  the  Cheyne- 
Stokes'  pnenomenon,  and  death  is  caused  by  paralysis 
of  the  respiratory  center.  Other  cases,  designated  as 
the  fulminant  form,  begin  with  the  most  severe  brain 
symptoms,  which  are  followed  at  once  by  coma,  and 
die  inside  of  a  few  hours.     In  the  third  variety  the 


DISEASES   OF    THE    BRAIN.  87 

course  is  more  protracted,  presenting  an  intermittent 
character  with  repeated  relapses.  The  duration  may 
then  cover  six  to  eight  weeks,  or  longer,  and  the  re- 
sult be  more  favorable.  But  even  here  a  fatal  ter- 
mination is  frequently  observed  or  serious  sequelce 
remain,  and  extreme  emaciation  occurs  under  these 
circumstances  (Klebs).  Again,  cases  have  been  ob- 
served during  certain  epidemics,  which  present  an 
abortive  form  of  the  disease.  These  generally  begin 
suddenly  with  high  fever,  delirium,  and  contraction 
of  the  neck ;  in  some  of  these,  the  fever  being  mild 
or  absent,  a  speedy,  favorable  termination  will  result, 
In  the  more  protracted  cases  of  this  form,  we  observe 
a  line  of  symptoms  of  cerebral  and  spinal  origin,  con- 
sisting in  irritation  and  paralysis  of  the  muscles  of 
the  eye,  producing  strabismus,  nystagmus,  ptosis, 
and  irregular  pupils.  Also  disturbances  of  the  special 
senses,  like  tinnitus,  deafness,  transitory  blindness,  op- 
tical neuritis,  otitis  media,  etc.  Besides  these  we  find 
contractions  of  the  muscles  of  the  face  accompanied 
by  stiffness  of  the  sterno-cleido-mastoid,  opisthotonos, 
etc.  Radiating  pains  in  the  extremities  are  frequent 
as  well  as  contractions  of  the  flexors ;  also  hemiplegia 
and  aphasia  are  frequently  observed.  The  tendon  re- 
flexes and  those  of  the  skin  may  be  increased  or  de- 
creased, or  entirely  absent.  Accompanying  symptoms 
may  be  found  in  spasm  of  the  bladder,  labial  herpes, 
diffuse  or  spotty  erythema,  and  in  severe  cases, 
petechiae.  Epistaxis  is  frequent,  also  swelling  of  the 
joints  and  diarrhoea.  Nephritis  and  diabetic  compli- 
cations are  rare;  the  urine  is  generally  normal  in 
quantity,  but  frequently  contains  albumin. 


88  PRESENT    STATUS   OF    PEDIATRICS. 

Amongst  the  sequelcB^  hydrocephalus,  deaf -mutism, 
deafness,  blindness,  psychical  weakness,  and  various 
neuralgias  are  most  prominent. 

The  diagnosis  is  not  difficult  as  long  as  the  disease 
occurs  epidemically.  In  sporadic  cases  the  initiative 
stage  may  leave  some  doubts,  but  the  characteristic 
symptoms,  which  will  soon  follow,  will  clear  this  up. 
Nevertheless  comparison  should  be  made  with  simple 
menmgitis  and  typhoid  fever.  The  course  of  tubercu- 
lar meningitis  is  usually  more  tardy,  and  the  emacia- 
tion preceding  this  affection,  as  well  as  the  family 
history,  will  make  its  exclusion  easier. 

The  prognosis  is  always  doubtful,  especially  with 
young  children,  and  in  fulminant  cases.  Protracted 
illness  will  prove  less  dangerous  to  life,  but  it  may 
leave  serious  and  lasting  disturbances. 

Treatment. — The  most  appropriate  remedies  in 
this  affection  well  be  aconitiun,  belladon7ia^  gelsemiiiui^ 
cicuta,  apis,  ciniicifiiga,  crotalus,  ciipricDi,  argentunt 
nitrieuDi,  Jiyoscyanms,  natruin  snlpJmricuni,  opimn, 
stramonium,  tabaciim,  veratrtim  album,  veratrum 
viride,  zincum.  Besides  these  the  study  of  the  fol- 
lowing remedies  will  be  required  in  some  cases: 
Bryonia,  helleborus,  camphora,  cannabis  indica,  can- 
tJiaris,  digitalis,  hydrocyanic  acid,  Jiypcricum,  ignatia, 
lycopodium,  nux  vomica,  pJiospJiorus,  plumbum,  rhus 
toxicodendron,  solanum,  sidpJiur,  tuberculi7i. 

Since  the  disease  occurs  epidemically,  and  on  ac- 
count of  its  infectious  nature,  however  slight,  it  will 
be  necessary  to  isolate  the  patient.  He  is  best  kept 
in  an  airy,  ventilated  room,  which  is  sufficiently 
darkened  and  away  from  all  noise.     Evacuations  and 


DISEASES    OF    THE    BRAIN.  89 

refuse  matter  must  be  speedily  disinfected  and  re- 
moved. Strict  observance  of  sanitary  rules  in  the 
household,  and  by  the  local  authorities,  in  places 
where  an  epidemic  has  entered,  will  soon  check  its 
progress.  I  have  more  confidence  in  the  effect  of  a 
well  selected  remedy  than  in  all  adjuvants,  as  baths, 
packs,  etc.,  for  the  extreme  hypersesthesia  of  the 
patient  commands  the  most  tender  care  as  to  rest 
and  quiet.  Water  may  be  freely  administered,  and 
if  it  becomes  necessary,  nutritious  fluids  w411  have 
to  be  injected  into  the  rectum. 

CHRONIC  HYDROCEPHALUS.— This  condition  is 
characterized  by  an  accumulation  of  an  excess  of  fluid 
in  the  ventricles  of  the  brain  or  intermening-eal ;  and 
this  may  be  either  congenital  or  acquired.  The  causes 
for  the  congenital  form  are  not  known,  though  it  is 
frequently  found  to  occur  in  various  children  of  the 
same  family.  Congenital  rickets,  syphilis,  and  de- 
privation of  the  parents  are  said  to  favor  its  develop-, 
ment.  The  acquired  form  shows  itself  sometimes 
soon  after  birth  when  it  may  have  started  intra- 
uterine; or  it  begins  after  the  closure  of  the  fonta- 
nelles  as  the  sequel  of  an  acute  meningitis.  Congeni- 
tal defects  of  the  heart,  producing  stagnation  in  the 
cerebral  circulation,  have  been  found  causative,  as 
well  as  severe  attacks  of  whooping-cough,  which  lead 
to  a  similar  stasis  by  repeated  passive  congestion. 

Symptomatolog'y. — The  congenital  hydrocepha- 
lus, like  the  one  acquired  early  in  infancy,  shows  a 
uniform  enlargement  of  the  cranium,  markedly  out 
of  proportion  to  the  small  size  of  the  face.  The 
frontal  bone  projects  forward,  the  occipital  almost 


90  PRESENT    STATUS    OF    PEDIATRICS. 

horizontally  backward.  All  the  flat  bones  are  more 
or  less  thinned,  except  the  frontal  and  parietal  emi- 
nences, which  are  thickened.  The  sutures  are  wide 
open,  the/^^z/^w^/Z^i- very  large  and  fluctuating.  The 
bones  at  the  base  appear  more  shallow,  also  the  roofs 
of  the  orbits  are  depressed.  If  hydrocephalus  develops 
after  the  bones  have  become  united,  the  enlargement 
of  the  cranium  is  less  rapid,  but  the  bones  may  sepa- 
rate again.  In  meningeal  exudation  the  cortex  of  the 
brain  is  very  anaemic,  and  the  convolutions  are  widely 
separated  by  the  enlarged  fissures.  The  cerebellum, 
the  spinal  cord,  and  the  cerebral  nerves  usually  remain 
normal.  Ventricular  exudation  enlarges  mainly  the 
lateral  ventricles,  giving  the  brain  the  appearance  of 
two  soft  fluctuating  bags.  The  fluid  is  generally 
clear,  of  a  slightly  yellowish-green  tinge,  and  contains 
very  little  albumin.  The  bodies  of  hydrocephalic 
children  are  but  poorly  developed,  and  show  a  great 
.contrast  against  the  enormous  head;  they  are  ema- 
ciated, the  muscles  are  flabby,  the  skin  is  dry,  the 
upper  extremities,  however,  grow  inproportionately 
long.  The  head  cannot  be  carried  in  an  erect  posi- 
tion, and  the  face  looks  even  smaller  on  account  of 
the  emaciation.  The  eyes  are  staring,  and  sometimes 
protrude  on  account  of  the  pressure  upon  the  orbits ; 
strabismus  and  ptosis  appear  in  addition.  Vision  is 
sometimes  irripaired,  but  the  rest  of  the  senses  seem 
normal.  The  mental  development  is  naturally  re- 
tarded, but  not  in  all  cases,  and  the  child  articulates 
imperfectly  os  not  at  all.  Sometimes  such  cases  be- 
come totally  idiotic.  The  upper  extremities  are  ca- 
pable of   making  voluntary  motions  which    show    a 


DISEASES    OF    THE    BRAIN.  qi 

slight  choreic  character,  while  the  lower  ones  are  in  a 
somewhat  paretic  state.  The  child  has  a  swaying 
gait  and  will  frequently  fall,  mostly  forward.  Re- 
gional convulsive  attacks,  laryngismus,  and  contrac- 
tions of  groups  of  muscles  are  by  no  means  rare. 
Circulation,  respiration,  and  digestion  are  normal. 
Paralysis  of  the  bladder  or  rectum  have  been  observed 
in  isolated  cases;  but  headache,  restless  sleep,  and 
mental  irritability  are  frequent. 

Prog'nosis. — The  course  of  hydrocephalus  is  gen- 
erally very  chronic,  and  only  children  having  a  large 
amount  of  accumulation  at  birth  will  soon  die.  Most 
cases  will  last  for  months  or  years,  complicated  by 
occasional  symptoms  of  acute  meningitis,  which  at- 
tacks are  followed  by  increased  effusion.  Death  is 
caused  by  paralysis  due  to  brain  compression,  or  by 
convulsions  and  coma;  these  latter  conditions  are 
found  to  be  due  also  to  hemorrhages  in  the  brain,  or 
to  acute  meningitis.  Pneumonia,  entero-colitis,  and 
eruptive  fevers  will  likewise  prove  fatal.  Should  the 
effusion  cease  to  increase,  the  patient  may  survive, 
but  will  most  generally  remain  idiotic.  Spontaneous 
discharges  of  the  fluid  through  the  ears,  nose,  orbits, 
or  fontanelles  have  been  occasionally  observed ;  they 
are  possible  consequences  of  an  injury,  and  may  lead 
to  recovery. 

Prophylaxis. — In  a  disease,  which  in  most  cases 
is  brought  into  this  world  with  the  birth  of  the  child, 
a  prenatal  prophylactic  treatment  in  suspected  cases 
may  be  of  greater  value  than  the  doubtful  trials  of 
restoration  afterwards.  The  care  of  the  mother,  who 
has  given  birth  to  a  hydrocephalus  previously,  may 


92  PRESENT    STATUS    OF    PEDIATRICS. 

prove  beneficial,  and  the  systematic  administration  of 
bone  salts  in  the  third  centesimal  trituration  during 
the  time  of  beginning  and  advancing  bone  formation, 
up  to  the  eighth  month  of  pregnancy,  has  had  good 
results  in  my  hands  on  various  occasions.  The  occa- 
sional prescription  of  a  high  potency  of  psorijiiun^  or 
sypJiilhmm  in  suitable  cases,  during  pregnancy,  will 
likewise  be  advisable.  The  effect  of  such  treatment 
is  often  surprisingly  good,  and  no  possible  harm  can 
result  from  it. 

Treatment. — A  case  of  chronic  hydrocephalus  will 
prove  a  great  test  for  the  extent  of  maternal  love  and 
devotion ;  for  such  a  child,  in  an  advanced  state  of 
the  disease,  is  a  helpless  and  pitiable  individual,  the 
more  so  the  older  it  grows.  Local  treatment,  as 
bandaging  with  adhesive  or  elastic  straps,  or  ' '  tap- 
ping," has  given  little  encouragement  and  often 
proved  dangerous.  Constitutional  treatment,  corre- 
sponding to  that  of  rhachitis,  is  most  beneficial,  and 
the  remedies  useful  there  will  do  everything  that  may 
tend  to  a  gradual  improvement  of  hydrocephalus. 
The  most  suitable  remedies,  therefore,  will  be  baryta 
carbonica^  baryta  iodata^  calcarea  carbo7iica^  calcarea 
phosphorica^  sulphur^  pJiospJwriis^  Jielleboriis^  thuja^ 
etc.  Acute  conditions  which  arise  during  the  exist- 
ence of  hydrocephalus  will  best  be  met  by  the  treat- 
ment specified  under  the  respective  affections.  The 
best  possible  hygienic  methods  should  be  employed  to 
improve  and  sustain  general  health,  and  all  possible 
annoying  influences  avoided. 

CONVULSIONS  {Eclampsia).— ^y  eclampsia,  or  in- 
fantile convulsions,  we  understand  more  or  less  gen- 


DISEASES    OF    THE    BRAIN.  93 

eral  clonic  and  tonic  spasms,  occurring  in  attacks, 
accompanied  by  unconsciousness,  and  without  an  an- 
atomical lesion  of  the  brain.  It  is  therefore  a  direct 
or  indirect  reflex  irritation  of  certain  motory  centers. 
Eclampsia  is  very  frequent  in  the  first  years  of  life, 
especially  during  the  first  eighteen  months.  The  un- 
developed state  of  the  infant's  brain,  and  the  conse- 
quent imperfection  of  the  controlling  or  inhibitory 
centers,  predisposes  most  extraordinarily  for  the 
marked  tendency  to  convulsions  during  this  early  age. 
The  causes  for  such  a  convulsive  explosion  are  many. 
Direct  brain  irritation  may  be  produced  by  active  and 
passive  hyperaemia,  or  by  anaemia  of  the  brain,  hy- 
drocephalus, pressure  during  birth,  toxaemia  from 
general  infection,  high  febrile  temperature,  uraemia, 
etc.  Reflexes  may  follow  all  possible  disturbances 
in  the  gastro-intestinal  canal,  the  genito-urinary 
organs,  or  sudden  impressions  upon  sight  or  hearing, 
even  grave  emotional  disturbances  of  the  nursing 
mother,  etc.  Many  children  are  predisposed  either 
by  rhachitis,  weak  constitution,  or  heredity.  The  lat- 
ter cause  predominates  on  account  of  parents  being 
neuropathic,  syphilitic,  or  intemperate. 

Symptomatology. — The  attack  occurs  suddenly, 
sometimes  preceded  by  irritability,  restlessness,  or 
loud  cries;  the  following  symptoms  varying  greatly 
in  intensity.  They  may  consist  in  simple  jerks  of 
single  muscles  or  groups  of  muscles  in  the  face,  eyes, 
or  extremities.  These  occur  mostly  in  young  infants 
from  irritation  of  the  digestive  organs.  A  marked 
convulsion  frequently  begins  with  a  spasm  of  the 
glottis,  as  if  the  child   were  choking;    or  rolling  of 


94  PRESENT    STATUS   OF    PEDIATRICS. 

the  eyes  upwards  with  twitching  of  the  face  and 
hands.  The  face  turns  pale,  the  eyes  are  turned  up- 
ward, the  pupils  enlarged.  There  is  twitching  in  the 
face  while  the  jaws  are  clinched,  or  there  may  be  a 
chewing  motion  with  grinding  of  the  teeth.  The 
child  becomes  unconscious  during  the  attack,  there 
is  stiffening  of  the  whole  body,  interrupted  respira- 
tion and  consequent  blueness  of  the  lips  and  face. 
This  picture  quickly  gives  way  to  clonic  spasms,  and 
after  a  few  repeated  jerking  contractions  of  the  hands, 
feet,  and  face,  the  child  passes  into  an  exhausted 
quietude,  during  which  respiration  becomes  regular, 
and  thus  the  attack  is  ended,  which  may  have  lasted  but 
a  few  seconds  or  minutes ;  a  dazed  condition  remains 
for  some  time  longer,  however.  More  severe  con- 
vulsions will  give  a  close  resemblance  to  an  epileptic 
fit.  The  entire  body  will  then  be  involved  and  will 
be  almost  thrown  about  by  the  forcible  muscular 
spasms,  while  in  other  cases  lasting  tonic  contractions 
will  produce  opisthotonos.  The  muscles  of  the  ex- 
tremities take  active  part,  the  face  is  distorted  and 
cyanotic,  froth  will  appear  at  the  mouth,  which  may  be 
bloody  from  the  patient  biting  his  tongue.  Respira- 
tion is  labored,  unconsciousness  complete,  stool  and 
urine  are  passed  involuntarily.  These  severe  attacks, 
which  may  last  from  two  to  fifteen  minutes,  pass  off 
in  the  manner  of  the  lighter  ones,  the  child  falling 
into  a  quiet  slumber,  remaining  somewhat  exhausted 
and  soporous  for  a  short  time. 

Several  such  attacks  may  follow  each  other  after 
longer  or  shorter  intervals  for  one  or  more  days. 
But  if  the  cause  is  a  gastric  disturbance,  an  evacua- 


DISEASES    OF    THE    BRAIN.  95 

tion  of  the  bowels,  or  an  attack  of  vomiting  during 
the  first  convulsion,  may  overcome  the  condition  and 
no  further  repetition  of  the  convulsions  will  occur. 
Severe  attacks  do  not  always  end  favorably,  for  grave 
complications  may  cause  a  fatal  termination,  as,  for 
instance,  spasm  of  the  glottis,  coma,  and  cerebral 
hemorragemay  induce  death.  A  tendency  to  eclamp- 
sia remains  for  years. 

Prognosis.  —  Prognosis  is  dependent  upon  the 
cause,  and  therefore  usually  not  unfavorable  except  in 
rhachitic  children,  when  lar}mgismus  complicates  the 
attack ;  also  in  very  severe  convulsions  which  repeat 
frequently,  the  prognosis  becomes  more  doubtful,  on 
account  of  the  possible  cerebral  or  meningeal  con- 
gestion and  hemorrhages. 

The  diagnosis  will  be  guided  by  the  observation 
of  one  or  more  attacks,  by  which,  however,  some  or- 
ganic cerebral  affection  cannot  always  be  positively 
excluded.  Such  an  affection  may  be  thought  of  if 
the  spasms  remain  semilateral.  After  prolonged 
watching  of  the  case,  the  absence  of  further  brain 
symptoms  will  diagnose  eclampsia ;  but  if  the  excit- 
ing cause  can  be  found  from  the  beginning,  diagno- 
sis becomes  less  difficult.  In  convulsions,  during  the 
prodromal  stage  of  acute  infectious  diseases  with 
high  fever,  meningitis  may  be  suspected.  Here  the 
further  course  of  the  affection  will  clear  up  the  doubt 
within  a  day  or  two.  It  is  often  difficult  to  determine, 
after  repeated  severe  attacks,  whether  epilepsy  exists 
or  not.  The  latter  will  become  probable  if  sustained 
by  a  family  history  and  if  no  direct  cause  for  the  at- 
tacks can  be  found. 


96  PRESENT    STATUS   OF    PEDIATRICS, 

Treatment. — Regarding  the  physician's  bearing  in 
the  treatment  of  convulsions,  Dr.  Tooker's  advice  in 
his  text-book  is  good.  He  says:  "  It  is  not  often  that 
the  physician  arrives  in  time  to  find  the  patient  in  the 
fit.  When  he  does,  the  most  important  thing  is  to 
preserve  a  calm,  well-poised  demeanor,  and  without 
unseemly  haste,  direct  the  various  persons  about" 
(and  send  most  of  them  out  of  the  room — M.  D.), 
and  in  this  way  a  quiet  atmosphere  is  secured  about 
the  patient,  on  whom  the  physician  himself  keeps  a 
watchful  eye.  (/.  <:.,p.  655.)  With  the  rest  of  Dr. 
Tooker's  recommendations,  I  am  sorry  not  to  be  able 
to  agree.  I  have  never  seen  any  good  derived  from 
baths  or  packs,  and  the  shock  connected  with  them 
often  tends  to  aggravate  the  convulsions.  When  it 
can  be  ascertained,  beyond  all  possible  doubt,  that 
the  child  has  partaken  of  a  large  amount  of  unsuit- 
able food,  the  quicker  this  is  out  of  the  body  the 
better,  and  a  sufficient  dose  of  castor  oil  may  be  all 
that  is  required.  For  the  same  urgent  reason  an 
enema  of  warm  water  may  be  given.  A  free  evacua- 
tion of  the  intestines  will  always  facilitate  abdominal 
circulation,  and  thus  be  indirectly  beneficial;  but 
emetics,  gum-lancing,  etc. ,  are  procedures  which  no 
conscientious  physician  will  resort  to  at  the  present 
day. 

No  matter  how  serious  the  attack,  undress  the  child 
entirely,  and  place  it  lightly  covered  upon  a  large 
bed.  Inquire  thoroughly  into  the  history  of  the  case, 
observe  closely  the  character  of  the  convulsions  and 
the  attitude  of  the  child.  Then  select  your  remedy 
in  accordance  therewith.    The  best  method  of  getting 


DISEASES    OF    THE    BRAIN.  97 

the  drug-  to  affect  the  patient  during  a  convulsion  is 
by  placing  a  few  globules  of  the  potentized  remedy 
inside  the  lips  or  under  the  tongue,  or  by  holding  the 
open  vial  closely  to  the  child's  nostrils  for  inhalation. 
CJiaiiwinilla^  cicuta^  cina^  belladonna^  calcarea  carbon- 
ica^  coffca^  ciipriiin^  Jiyoscyanius^  ignatia^  ipecacuanha^ 
kali  broviictnn^  kreosotnni^  magnesia  phosphorica,  sili- 
cea^  strainonimn^  and  zinciun  have  their  well-known 
characteristic  indications,  and  will  act  promptly  in 
their  respective  sphere.  Monotropa  iiniflora  has  been 
recommended  by  all  who  have  employed  this  drug 
empirically  in  convulsions,  but  as  yet  pathogentic  in- 
dications are  wanting. 

EPILEPSY.— This  affection,  though  not  strictly  a 
disease  of  childhood,  is  not  uncommon  during  the 
early  period  of  life,  as  has  been  intimated  in  the  re- 
marks on  diagnosis  of  eclampsia.  By  the  term  "epi- 
lepsy '.'  we  understand  a  chronic  functional  disease  of 
the  brain,  often  accompanied  by  degenerative  pro- 
cesses of  that  organ,  which  is  characterized  by  recur- 
rent attacks  of  impairment  or  loss  of  consciousness, 
which  may  or  may  not  be  attended  with  convulsions. 
It  generally  begins  before  the  age  of  twenty,  mostly 
at  commencing  puberty ;  but  cases  occurring  in  chil- 
dren under  four  years  of  age  are  more  numerous  than 
has  been  formerly  suspected.  Epileptics  frequently 
show  some  psychical  disturbance  even  at  times  when 
free  from  the  attack. 

The  etiology  is  still  obscure,  though  experimental 
researches  locate  the  origin  of  epileptic  convulsions  in 
the  frontal  and  lateral  regions  of  the  cortex  of  the 
brain.     Therefore  various  pathological  processes  of 


98  PRESENT    STATUS    OF    PEDIATRICS. 

this  organ  itself  and  its  membranes,  or  of  the  cra- 
nium, may  cause  functional  disturbances  in  these 
motor  regions,  and  thus  induce  symptomatic  or  focal 
epilepsy.  Such  causes  consist  in  tumors,  gummata, 
tubercles,  exostoses,  abscesses,  traumatic  effects,  etc. 
Also  reflex  irritations  originating  in  the  nose,  ear, 
larynx,  prepuce,  etc. ,  in  fact,  at  any  of  the  orifices  of 
the  body,  may  develop  epilepsy.  A  hereditary  predis- 
position undoubtedly  exists  in  many  cases ;  in  others, 
it  may  be  acquired.  Injury  during  birth,  premature 
mental  exertion,  the  use  of  alcohol  in  children,  mas- 
turbation, and  mental  impressions,  as  intense  fright, 
fear,  or  joy,  have  been  reported  as  exciting  causes. 

Symptomatolog'y. — The  first  attack  may  occur 
suddenly  in  the  form  of  intense  convulsions,  even  at 
an  early  age ;  but  the  disease  can  also  develop  gradu- 
ally. In  the  latter  instance  there  will  be  an  occasional 
momentary  loss  of  consciousness,  the  child  staggers 
and  falls,  or  it  need  not  even  go  so  far ;  he  will  simply 
drop  things  from  his  hands  with  an  expression  of 
total  absent-mindedness  and  a  vacant  look  in  his  face. 
Afterwards  he  will  not  know  what  has  happened,  and 
in  such  cases  punishment  for  carelessness  is  highly 
unjust.  In  many  of  these  conditions  the  child  will  be 
shy  in  his  disposition,  and  the  observer  finds  slight 
twitching  in  the  face  accompanying  the  staring  look, 
during  such  an  attack  of  unconsciousness  (petit  mal). 
The  confirmed  paroxysms  (grand  mal)  are  much  more 
intense.  Generally  an  irritable  state,  peevishness  with 
vertigo  or  anxiety,  tinnitus,  nausea,  a  sense  of  stran- 
gulation, or  hallucinations,  etc.  (the  aura),  precede  a 
typical  attack,  which  begins  within  a  few  seconds. 


DISEASES    OF    THE    BRAIN.  99 

With  a  loud  cry  the  child  sinks,  falls,  or  is  thrown 
down  forcibly,  his  face  becoming  very  pale.  After  a 
momentary  quiet  the  head  is  drawn  back,  the  eyes 
stare  and  are  turned  upwards  or  sideways  with  en- 
larged pupils.  The  whole  body  presents  a  tonic  ri- 
gidity. Then  the  pale  face  becomes  congested,  dark 
red,  even  cyanotic,  severe  general  clonic  spasms  fol- 
low, during  which  the  tongue  is  often  caught  between 
the  teeth  and  a  bloody  froth  oozes  from  the  mouth. 
Flatus  and  urine  may  escape  involuntarily,  stool  less 
frequently ;  respiration  is  irregular  or  accelerated  and 
has  a  peculiar  loud  snoring  sound.  The  pulse,  which 
is  weak  in  the  beginning,  gradually  becomes  fuller 
and  quicker.  After  a  few  minutes,  the  convulsions 
lessen  and  cease  with  a  few  single  jerks  of  the  ex- 
tremities, or  with  a  general  tremor  running  through 
the  body.  The  face  again  appears  pale  and  with 
perspiration  breaking  out  all  over  the  body,  the 
breathing  gradually  becomes  regular.  A  heavy  sleep 
follows,  or  the  patient  comes  out  of  the  attack  like 
awakening  from  a  fearful  dream,  and  complains  of 
headache.  Such  attacks  will  repeat  after  long  inter- 
vals at  first,  but  later  on  they  become  more  frequent. 
In  some  cases  they  occur  only  at  night.  They  vary 
in  intensity  and  may  be  limited  to  single  groups  of 
muscles.  At  the  beginning  of  epilepsy  the  condition 
of  the  body  and  mind  remain  apparently  normal  dur- 
ing the  intervals;  but  soon,  especially  after  severe 
attacks,  psychical  and  nervous  disturbances  appear. 
The  children  show  a  timid,  shy  disposition,  which 
often  passes  into  loss  of  memory,  melancholia,  idiocy, 
or  mania ;  some  epileptics,  however,  continue  in  good 


100  PRESENT    STATUS    OF    PEDIATRICS. 

mental  condition  throughout.  Frequently  attacks 
are  followed  by  more  or  less  rise  of  temperature,  al- 
buminuria, polyuria,  glycosuria,  and  retinal  hemor- 
rhages. Epilepsy  is  always  chronic,  lasting  for  many 
years,  often  through  a  long  life.  Puberty  may  in- 
crease or  decrease  the  malady,  and  a  marked  cessa- 
tion of  the  attacks  has  been  observed  during  and  af- 
ter intercurring  fevers. 

Prog'nosis.  —  Hereditary  epilepsy  gives  little 
chance  for  a  cure ;  w^hile  the  acquired  form,  depend- 
ing upon  reflexes  or  traumatic  causes,  is  more  promis- 
ing. According  to  Lloyd  (Starr's  text-book)  "brain 
surgery  has  received  focal  cases  due  to  gross  lesions, 
but  even  in  these  cases  relapses  have  occurred." 

The  diagnosis  depends  upon  the  characteristic 
repetition  of  the  attacks,  combined  with  mental 
changes  in  the  child,  and  will  be  greatly  aided  by 
the  admission  of  heredity.  Hysteria  has  to  be  con- 
sidered as  well  as  feigned  epilepsy,  which  is  hardly 
ever  practiced  by  children,  and  can  be  disclosed  by 
a  careful  analysis  of  the  attack.  Valuable  points  in 
diagnosis  are  the  cessation  of  reflexes  of  the  cornea 
and  the  pupils,  also  the  complete  loss  of  conscious- 
ness, which  is  rare  in  other  forms  of  convulsions, 
though  in  isolated  instances,  with  localized  epileptic 
spasms,  consciousness  may  not  be  entirely  lost. 

Treatment. — During  an  epileptic  attack  the  pa- 
tient should  be  placed  in  a  horizontal  position,  on  a 
mattress  or  some  other  soft  material,  to  prevent  seri- 
ous injury  during  the  often  violent  convulsive  move- 
ments. All  methods  of  treatment  at  that  time  have 
proved  of  little  avail,  and  it  is  best  not  to  interfere, 


DISEASES    OF    THE    BRAIN.  •  lOI 

but  simply  to  watch  and  protect  the  patient.  In- 
halations of  aniyl  nitrite^  ether ^  or  chloroform  have 
sometimes  had  beneficial  results,  but  even  those  who 
advocate  this  practice,  warn  of  its  dangers,  especially 
with  reference  to  chloroform.  In  my  experience  any 
suppression  of  the  individual  attack  predisposes  to 
more  frequent  repetitions.  After  the  attack  the  pa- 
tient should  be  allowed  to  sleep  quietly  until  spon- 
taneous awaking  occurs. 

The  epileptic  seizure,  being  but  a  group  of  symp- 
toms of  a  deeply  rooted  affection,  should  only  form  a 
part  of  the  study  in  our  cases.  Wherever  the  cause 
is  known  it  should  be  removed  if  possible ;  and  the 
whole  mode  of  life  of  the  patient  should  be  so  modi- 
fied as  to  insure  mental  rest.  All  exciting,  emotional 
influences,  even  those  of  a  pleasurable  nature,  must 
be  avoided.  Gentle  educational  methods  should  be 
employed,  and  moderate  exercise,  both  mentally  and 
bodily,  is  advisable,  while  all  undue  exertion  in 
either  direction  is  objectionable.  The  diet  should  be 
of  simple  but  nourishing  character  and  to  a  great  ex- 
tent, but  not  absolutely,  vegetable. 

It  will  take  years  of  observation  to  be  able  to  judge 
of  the  ultimate  result  of  a  cure  of  epilepsy.  We 
have  a  chance  for  eventual  success,  as  long  as  the  in- 
tervals between  the  attacks  can  be  prolonged  and  the 
general  condition  of  the  patient  improves,  especially 
in  his  mental  sphere.  The  prescription  should  there- 
fore mainly  rest  upon  constitutional  indications,  and 
nothing  in  the  history  of  the  patient  since  birth,  nor 
in  his  family  history,  should  escape  our  notice.  The 
peculiarities  of  the  attacks  themselves  and  the  time 


102  PRESENT    STATUS    OF    PEDIATRICS. 

of  their  occtirrence  are  of  great  importance,  and 
should  be  investigated  in  every  detail.  A  single 
remedy  will  rarely  suffice  to  cure  a  case  of  confirmed 
epilepsy,  but  a  course  of  remedies,  carefully  selected, 
following  each  other  in  symptomatic  relationship,  and 
repeated  at  long  intervals,  have  often  brought  about 
very  satisfactory  results.  The  extended  list  of  reme- 
dies found  in  various  homoecTpathic  text-books  give 
little  encouragement,  especially  as  they  are  most  all 
recorded  with  reference  to  their  influence  on  the  con- 
vulsive nature  of  the  disease.  The  more  we  leave 
this  in  the  background  when  taking  the  case,  and  the 
more  stress  we  lay  on  the  individual  characteristics  of 
the  patient,  the  more  will  we  find  that  Hahnemann's 
antipsorics  and  a  few  other  remedies  will  cure  the 
epileptic  habit  more  frequently  and  certainly  than 
many  of  those  rare  drugs,  the  provings  of  which  are 
incomplete  and  unreliable ;  and  the  empirical  admin- 
istration of  which  tends  to  discourage  patient  and 
physician.  Therefore  argejittim  nitricuvi^  calcarea 
carbonica,  calcarea  pJwspJiorica^  causticum^  ignatia^ 
kali  carho7iiciim,  natrui7i  inter iaticiim^  natrum  sul- 
phuricuin,  nitric  acid^  mix  vomica^  opitim^  platimini^ 
plumbum^  psorimim^  silicea^  stapJiysagria^  sypJiilimini^ 
thuja,  zincum,  will  be  most  frequently  employed; 
but  cases  will  arise  which  point  strongly  to  another 
group  in  which  the  convulsive  nature  is  more  promi- 
nent: Absinthe,  agaricin,  artemisia,  aster ias  riibens, 
belladonna,  bufo,  cannabis  indica,  cicuta,  crotalns, 
ciiprnni,  Jiydrocyariic  acid,  hyoscyamiis,  lachesis,  caja 
tripiidians,  a^nanthe,  stanriiim,  tarantula  Jiisparia, 
zizia. 


DISEASES   OF    THE    BRAIN.  ^03 

The  bromides^  powerful  palliatives,  but  not  cura- 
tives, are  looked  upon  with  growing  suspicion  even 
by  writers  of  the  old  school.  Horatio  C.  Wood  says 
with  reference  to  this:  ''Although  Albertoni  has 
shown,  by  direct  experiment,  that  they  diminish  de- 
cidedly the  irritability  of  the  cerebral  cortex  in  the 
motor  zone,  they  are  palliative  rather  than  curative, 
and  act  only  while  present  in  the  cortex.  They  do 
not  remove  the  tendency  to  epileptic  attacks,  but  an- 
tagonize the  action  of  such  tendency,  and  must,  there- 
fore, in  most  cases  be  administered  continuously  for 
many  years  after  the  occurrence  of  the  last  fit. "  (Pep- 
per's text-book,  vol.  I,  p.  625.) 

Donkin,  in  his  Diseases  of  Childhood,  remarks  with 
reference  to  bromides,  that  their  continued  employ- 
ment during  childhood  is  not  to  be  recommended,  on 
account  of  the  eminently  depressing  effects  upon  the 
nervous  system  and  the  mind,  setting  up  a  perma- 
nent listless  habit,  also  producing  anorexia  and  dys- 
pepsia difficult  to  overcome. 

To  facilitate  the  selection  of  the  remedy  in  cases 
of  brain  disease,  I  have  arranged  the  following 
"  Repertory  of  Characteristics,"  which,  when  used  in 
conjunction  with  the  Materia  Medica,  will  lead  to  the 
proper  comparison  of  competing  drugs  and  thus  to 
the  ultimate  selection  of  the  remedy  in  the  case : 


I04  PRESENT    STATUS    OF    PEDIATRICS. 

REPERTORY  OF  CHARACTERISTICS. 

Mind. 

Seems  afraid  of  something;  starts  as  in  affright:  Opium. 
Child  whimpers ;  ready  to  cry  at  any  little  annoyance ;  sheds 
tears  copiously :  Pulsatilla. 

Mild  and  tearful :  Alumina,  ignatia^  Pulsatilla. 

Sudden  change  of  disposition :  Bryottia. 

Almost  constant  moaning :  BELLA  DONNA ,  helleborus. 

Angry,  reluctant:    Chamomilla,   nux  voinica;   and  hot  all 
over  body:  Zinciwi. 

Angry,  worse  when  kindly  spoken  to;   striking  about,  un- 
willing to  have  anybody  near  them :  Helleborus. 

Nervous  temperament:  Cocculus,  coffea.secale,  staphysag- 
ria. 

Bites  those  who  hold  her:  Strafnonium. 

Irritable,  peevish:  Cha)n07nilla,  cina,  nux  vomica. 

Delirium  with  jerking  of  the  limbs:  HYOSCYAMUS. 

Delirium,  muttering  and  indistinct  speech :  Hyoscya^nus. 

Furious  delirium  and  violent  pains:  BELLADONNA. 

Furious  delirium  with  intervals  of  prostration :  Stra7n07iium, 

Delirium  with  wild  fancies:  CIMICIFUGA. 

Mild  delirium;   severe  shooting  and  tearing  pains:   BRY- 
ONIA. 

Merry  delirium ;  Stramotiiuni. 

Great  loquacity ;  pronounces  incoherent  words  now  and  then- 
Stramonium. 

Peevish  and  fretful:   CALCAREA  PHOSPHORICA. 

Peevish  and  cross:  CINA. 

Desire  to  escape  from  bed  and  room ;  loud  screams,  frequent 
and  deafening :  Stra77ioniu7n. 

Sharp  shrill  screams  when  asleep  or  awake :  A  PIS. 

Frequent  spells  of  screaming  without  apparent  cause:  CAL- 
CAREA  CARBONICA. 

Often  screaming  and  grasping  with  the  hands :  CALCA  REA 
PHOSPHORICA. 

Picking  at  the  bedclothes:   CINA,  hyoscya7nus. 

Apathetic  mood :   GELSEMIUM,  calcarea  phosphorica. 


DISEASES   OF    THE    BRAIN.  105 

M IND— Concluded. 
Listless  and    apathetic,  hardly  answers,    sinking    back  in 

apathy:  PHOSPHORIC  ACID. 
Complete  apathy:  Helleboriis. 
Stupor:    Apocynum  cannabinuin,  helleborus,  hyoscyainus, 

strariionium. 

Head. 

Sweats  heavily  about  the  head:  CALCAREA  CARBON- 
IC A. 

Profuse  sweat  about  the  head  at  night:  SILICEA. 

Cold  head  sweating:  C  ale  are  a  carbonic  a. 

Profuse  sweat  on  the  head  of  a  musk-like  odor:  APIS,  sul- 
phur. 

Dry  hot  head:  Sulphur. 

Great  heat  of  the  head  and  whole  body:  BELLADONNA. 

Foiitanelles  wide  open:  CALCAREA  CARBONICA, 
CALCAREA  PHOSPHORICA. 

Sutures  opened,  forehead  projecting:  APOCYNUM  CAN 
NA.BINUM. 

Burning  skin,  with  sweat  on  head  and  forehead:  Stramo- 
niu7n. 

Constant  relapsing  of  the  head  on  raising  the  trunk ;  HEL- 
LEBORUS,  yETHUSA. 

Head  sinks  backward,  as  if  too  heavy:  SULPHUR. 

Child  often  moves  its  trembling  hand  to  the  head:  HEL- 
LEBOR  US. 

Puts  the  hands  to  the  head,  which  he  strikes  now  and  then : 
Stra77i07tiu7n. 

Strikes  head  with  fists,  as  though  for  temporary  relief:  AR- 
SENIC. 

Bores  the  head  backward  into  pillow:  BELLADONNA^ 
cicuta. 

Eyes. 

Glittering  of  eyes :  Stra77i07iiU77i. 

Sparkling  eyes,  with  red  face:  BELLADONNA. 

Rolling  and  squinting  of  eyes:  APIS,  bellado7i7ia,  hellebo- 


lOO  PRESENT    STATUS    OF    PEDIATRICS. 

Eyes — Concluded. 

Strabismus:  HELLEBORUS. 

Strabismus,  right  convergent,  left  divergent:    Strafnonmm. 

Strabismus,  as  it  were,  from  pressure:  CALCAREA 
PHOSPHORICA. 

Rolling  of  eye-balls  without  winking :  Apis. 

Eyes  roll  about  in  their  socket:  BR  YON  I  A. 

Eyes  at  times  closed,  at  others  wide  open:  BR  YONIA. 

Eyes  half  opened,  with  sopor:  Opium. 

Eyes  half  opened,  with  pupils  turned  sideways  or  upwards, 
and  convulsive  movement  of  the  lips :  Helleboriis. 

Dilated  pupils:  APIS,  BELLADONNA,  HELLEBO- 
RUS, SULPHUR. 

Contracted  pupils :  Stra7)ionium,  opiiwi. 

Alternate  contraction  and  dilation  of  pupils:  Carbolic  acid. 

Power  of  vision  entirely  gone,  with  dilated  pupils:  Digita- 
lis. 

No  evidence  of  seeing  when  light  was  thrust  towards  eyes : 
Apis,  OPIUM. 

Wild,  staring  look:  HYOSCYAMUS,  stramoniu7n. 

Sight  of  one  eye  totally  lost,  the  other  slightly  sensible: 
APOCYNUM. 

Eye-balls  seem  distended  and  protruding:  CALCAREA 
PHOSPHORICA. 

Eyes  sunk:  Arsenic,  bufo,  stanmim,  staphysagria. 

Swelling  above  the  upper  eye-lids:  KALI  CARBONI- 
CUM. 

Convulsive  motions  of  eyes  and  lids:  Ignatia. 

Eyes  closed,  on  lifting  the  lids  eyes  stare  upwards:  Cicuta. 

Ears. 

Suppressed  otorrhoea:  Pulsatilla,  sulphur. 
Ears  cold:   Calcarea  phosphor ica. 
Loss  of  hearing:  Apis,  phosphorus. 
Hearing  inordinately  acute:  Opium. 

Nose. 

Nostrils  dirty  and  dr>^:  Helleborus,  zincum. 
Frequent  rubbing  of  the  nose :  Helleborus. 


DISEASES   OF    THE    BRAIN.  107 

Nose — Concluded. 
Constant  picking  the  nose:  Cma. 
Point  of  nose  cold :  Calcarea  phosphorica. 

Face. 

Red  face:  Hyoscyamus;  crimson:  Bryonia. 

Redness  or  heat  of  the  face,  with  sparkling  eyes :  Belladonna. 

Face  red,  almost  brown-red :  Bryonia. 

Dark  red  hue  on  face:  Gelse7mu?n,  belladonna. 

Flushes  of  heat :  Sulphur. 

Sudden  change  of  color  in  the  face:  Bryonia. 

Frequent  change  of  color  in  the  face:  Sulphur. 

Face  bloated  and  highly  congested:  Belladonna. 

Face  pale  and  waxy :  Apis,  arsenic. 

Face  pale  and  oldish  looking:  Artemisia  vulgaris. 

Hippocratic  countenunce :  Car  bo  vegetabilis. 

Face  pale,  sallow :  Calcarea  phosphorica. 

Cold  sweat  on  the  face :  Calcarea  phosphorica. 

Forehead  covered  with  a  cold,  clammy  sweat:  Veralrujn 
album. 

Cold  sweat  on  face,  hands,  and  feet:    Veratrum  viride. 

Passes  hand  over  the  face  as  though  trying  to  brush  some- 
thing off:  Nux  vomica. 

Rubs  face  and  eyes  indignantly:  Squilla. 

Constant  motion  of  the  jaws,  as  if  chewing:  BRYONIA, 
helleborus. 

Convulsive  motion  of  the  lips :  Ignatia. 

Dropping  of  the  lower  jaw:  Helleborus,  opium. 

Lock-jaw:  Cuprum,  strafnonium. 

Swollen  under-lip:  Calcarea  phosphorica. 

Looks  stupid :   Gelsemium. 

Looks  frightened,  with  sardonic  smile:  Stramonium 

Teeth. 

Grinding  of  the  teeth:  Apis,  cuprum,  stramonium. 

Child  grasps  at  its  gums  continually,  as  though  they  were 

painful:   Silicea. 
Scorbutic  gums:  Mercurius. 


I08  PRESENT    STATUS    OF    PEDIATRICS. 

Tongue. 

Dry,  3-ellow,  or  brown  coated  tongue:  Bryonia. 
Tongue  quite  clean,  but  vomiting  frequently :   Cina. 
Tongue  dry  and  red ;  previously  black :  Helleboriis. 
Child  regularly  protrudes  and  retracts  the  tongue  in  fever: 

Sulphur. 
Tongue  is  darted  back  and  forth  with  great  rapidity,  like  a 

snake's:  Cupruin  aceticum. 

Eating"  and  Drinking. 

Dysphagia:  Stramonium. 

When  water  was  put  into  his  mouth,  no  effort  of  swallowing 
was  made :  Apis. 

Hasty,  impetuous  drinking  and  swallowing :  Bryonia,  helle- 
dorus,  strainojiiuni. 

Drinking  and  swallowing  water  eagerly  in  sopor:  Artemisia 
vulgaris. 

Desires  cold  water  often,  drinks  but  little  at  a  time:  AR- 
SENIC. 

Very  thirsty,  desires  only  cold  water  or  ice :   Veratrum  album. 

No  thirst:  Apis,  Pulsatilla. 

Children  refuse  mother's  breast:  Calcarea phospJiorica. 

Hiccough:  Cicprum,  hyoscyamus,  stramonium. 

Constant  nausea  without  relief:  Ipecacuanha. 

Vomiting  of  mucus:    Cuprtim. 

As  soon  after  drinking  as  the  water  gets  warm  in  the  stomach,, 
it  is  vomited:  B  HO  SB  HO  R  US. 

Epigastrium,  great  pains  in  the:  ^Blsculus  hippo c as tanuni, 
cuprum. 

Urine. 

Scanty:  BRYONIA,  BULSATILLA,  A  BIS,   HELLE- 

BOB  US,  zincum. 
Suppressed:  Apis,  apocynum  cannabinujn,  stramonium. 
Large  quantities  of   colorless   urine,  especially  during  the 

night:  BHOSBHORIC  ACID,  squill  a. 
Profuse  or  scanty:  Apis,  stra?noniu?n. 
Urine  has  putrid  odor :   Sepia. 

Red  sediment  on  diaper:  Lycopodium,  sarsaparillOr, 
Clay-colored  sediment:  Sepia. 


DISEASES    OF    THE    BRAIN.  IO9 

Respiration. 

Quick,  moaning:  Bryonia. 

Labored,  occasionally  with  deep  sighs :  Helleboriis. 

Dyspnoea:  Laurocerastis. 

Sighing  and  sobbing  frequently:  Igtiatia,  plicmbitm. 

Very  heavy,  like  death  rattle :  Pulsatilla,  tar  tar  us  emeti- 

cus. 
Breath  cold :   Car  bo  veg-etabilis. 

Pulse. 

Irregular,  slow:  Apis,  helleborus,  Pulsatilla,  digitalis. 

Very  rapid :  Sulphur,  veratrum  viride. 

Very  feeble:  yEthusa,  veratrum  album. 

Throbbing  of  the  carotids:  Belladofina,  hyoscyamtis. 

Limbs. 

Coldness  of  hands  and  a  bluish  appearance  of  the  fingers: 
Cuprum. 

Coldness  of  limbs,  especially  the  knees:    CARBO    VEGE- 
TABILIS. 

Cold  and  clammy  sweat  upon  the  thighs  and  legs:  MER- 
CURIUS. 

Coldness  of  feet  and  legs :  Phosphorus. 

Feet  in  constant  motion:  Zincum. 

Involuntary  motions  of  the  extremities:   APOCYNUM. 

Involuntary  throwing  or  whirling  about  of  one  arm  and  one 
leg:  Helleborus. 

Jerking  of  the  limbs:  Hyoscyamus,  CICUTA. 

Trembling  of  the  limbs :  Apis. 

Stiffening  of  the  limbs :  Carbolic  acid. 

Uncertain,  tottering  gait:  Bryo?tia,  CALCAREA  PHOS- 
PHORIC A. 
•  Single  parts  convulsed :  IGNA  TIA . 

Left  side  had  been  entirely  motionless  for  two  days,  moved 
right  arm  and  leg  occasionally :  Apis. 

Starting  and  jumping  in  a  drowsy  state:  BELLADONNA. 

Starting  frequently  with  screams  and  howling:  Helleborus. 

Inability  to  raise  oneself  alone :  HELLEBOR  US,  stramo- 


no  PRESENT    STATUS   OF   PEDIATRICS. 

Limbs — Concluded. 
Great  prostration:  ARSENIC,  CARBO  VEGETABILIS, 

VERA  TR  UM  A  LB  UM. 
Nervous  and  restless,  ACONITE;  with  convulsions,  APIS. 
Convulsions,  with  great  restlessness   between  the  attacks: 

ARGENTUM  NITRICUM. 
Spasms  commence  mostly  in  fingers  and  toes :   Ctiprujn. 
Body  bent  far  backward  during  the  convulsions :    Veratram 

viride. 
Occasionally  sinking  spells,  regularly  about  the  middle  of 

the  day:  SULPHUR. 

Sleep. 

Snoring:  Opium, 

Screams  during  sleep:  APIS,  helleborus. 

Comatose:  APOCYNUM,  ARTEMISIA  VULGARIS, 
Ctcpriwi. 

Semi-comatose,  drowsy  state:  BELLADONNA,  (xthiisa, 
GELSEMIUM,  opium. 

Soporous  state,  with  half-open  eyes  and  red  face:  OPIUM. 

Dull  and  drowsy  after  waking,  as  if  intoxicated:  Opiiwi. 

Dull  and  inclined  to  sleep  all  the  time ;  no  sooner  roused  than 
wants  to  go  to  sleep  again ;  sleep  normal :  Phosphorus. 

Sleeps  nearly  all  the  time,  but  only  in  short  naps:   Sulphur. 

Particularly  wakeful  and  restless  after  3  a.  m.  :  NUX  VOM- 
ICA. 

On  awakening,  evidence  of  fear:  Strainoniinn,  zincu7n. 

Attacks  Begin— 

Arm,  in:  Belladomta. 

Abdomen,  in:   Calcarea  carbonica. 

Epigastrium,  in:    Nux  vomica,  glonoinufn. 

Fingers  and  toes,  in  the:  jEthusa  cyjiapium,  cuprum,  hy- 
drocyanic acid. 

Buttocks,  in:   Sepia. 

Face,  in:  Belladonna,  chamomilla,  dulcamara,  hyoscya- 
mus,  ignatia,  lycopodium,  mercurius,  sccale,  stramo7iium. 

Heel,  right  in  the — going  to  vertex :  Stramonium. 

Head,  in — going  downwards :   Cicuta. 


DISEASES   OF    THE   BRAIN.  Ill 

Attacks  Begin — Concluded. 
Ani,  sphincter:  Colchicum. 

Sleep,  during:  Biifo,  causticum,  chamojmlla,  lachesis, 
opium. 

Causes. 

Wet-nurse— vexation  of:  Nux  vomica,  opium. 

Wet-nurse — grief  of:  Ig7iatia. 

Wet-nurse — fright  of:  Aconite,  igftatia. 

Excitement — great — of  child — with  vexation:  Ckamomilla, 
kali  broiniciim,  nux  vojuica. 

Excitement,  pleasurable:  Cocculus,  coffea. 

Discharges  suppressed:  Asafcctida,  bryonia,  campohora, 
sulphur. 

Eruption  suppressed:  Agaricus,  atitimonium  tartaricu?n, 
bryom'a,  calcarea  carbonica,  causticum,  cainphora,  cu- 
prum aceticum,  ipecacuanha,  strainonium,  sulphur, 
zincujn. 

Touch  of  larynx,  the  least :  Cantharis. 

Touch  of  eyelids :  Coccus  cacti. 

Touch  of  the  feet:  Ntix  vomica. 

Punishment:  Ignatia. 

Pressure  on  spine :    Terebinthina. 

Laughing  excessively :  Coffea,  ignatia, 

Drinking,  hasty:  Bellado7ina,  hepar,  hyoscyamus,  ig7iatia. 

Vaccination,  after:  Silicea. 

Whooping-cough:  Arse7iic,  bellado7ina,  cha77i077iilla,  ca7i- 
tharis,  cupruDi,  drosera,  hydrophobi7ium. 

Fright:  Aconite,  gelsemium,  kyoscyat7ius,  ignatia,  kali 
bromicum,  opium,  stra7no7iiu7n. 

Sun,  heat  of:  Bellado7i7ia,  glonoi7iu77i,  7iux  vo77iica,  sul- 
phur. 

Indigestion:  Ipecacuanha,  7iux  V077tica,  Pulsatilla. 

Worms:  Asafcetida,  calcarea  carbonica,  cicuta,  cina,  hy- 
oscya77ius,  ig7iatia,  77iercurius,  sabadilla,  stan7ium,  sul- 
phtir. 

Dentition:  Belladon7ia,  calcarea  carbonica,  cha77i07}iilla, 
ci7ia,  cupru77i,  dolichos,  ignatia,  podophyllin,  stannu77i, 
stra77ioniu7n. 


112  PRESENT    STATUS    OF    PEDIATRICS. 

Time  of  Appearance  and  Ag'gravation. 

Daybreak,  at:  Platina. 

Morning,  in  the:  Artemisia  vulgaris,  causticum,  crotahis 
horridiis,  secale,  sulphur,  tabacum. 

9  A.  M. :  Lyssift,  nafrinn  viuriaticum. 

Noon:  Acoftite. 

4 — 8  p.  M. :  Lycopodium. 

8  p.  M. :  Arse7iic. 

IIP.  M. :  Opium. 

Night,  at:  Arsenic,  artemisia,  calcarea,  china,  cuprtnn, 
digitalis,  hyoscyamus,  kali carbonictim,  lycopodium,  mer' 
curius,  nux  vomica,  plumbum,  secale,  silicea,  sulphur. 

Midnight:  China,  crocus. 

2  A.  M.,  until:  Kali bromicuDi. 

3  A.  M. :  Agaricus,  kali  car bo?ticu7n. 

New  moon:  Bufo,  causticuni,  cuprum,  kali  bromicum,  si- 
licea. 

Full  moon:  Calcarea  carbonica,  kali muriaticuni. 

Supper,  after:  Zincum. 

Exercise,  during:  Bryojiia. 

Eating,  while:  Hyoscyamus,  ignatia,  nitric  acid. 

Flowing  water,  hearing:  Hydrophobinum. 

Thunderstorm:  Agaricus,  7iatrum  carbonicum,  rhododeti- 
dron,  silicea. 

Noise:  Coffea,  nux  vomica,  stramonium,  strychtiine. 

Light  strong:  Stramonium. 

Back,  lying  on:   Calcarea phosphorica. 

Swallowing,  while:  Nux  vomica,  hydrophobinuni ,  stramo- 
fiium. 

Stool,  during:  Arsenic,  chamomilla,  magnesia  phosphorica, 
7nercurius,  Pulsatilla,  sulphur,  veratru7n  album. 

Midnight,  after:  Arsenic. 

Morning  and  evening:  China. 

After  the  Attack. 

Legs  and  knees  bent  and  spread:  Plati7ium. 
Consciousness    returns   slowly,    with   continuing  paralysis: 
Plumbinii. 


DISEASES    OF    THE    BRAIN.  II3 

After  the  Attack — Concluded. 
Chest,  oppression  of  :  Ignatia. 
Delirium:  Kali chloricmn. 
Abdomen,  great  sensitiveness  of :  Bryonia. 
Prostration  marked:  Arse?tic,  arteinisia,  absinthe. 
Child  cries  and  twists  until  next  attack:   Cuprtim. 
Breath,  gasping  for:  Laurocerasiis. 
Soporous  sleep:  Absinthe,  arteinisia,  belladonna,  cenant he, 

otiuni. 
Urine,  profuse,  clear:  Ctcprum. 


114  PRESENT    STATUS    OF    PEDIATRICS. 


CHAPTER  V. 


DISEASES  OF  THE  SPINAL  CORD. 

BY  EUGENE  F.  STORKE,  M.  D. ,  PROFESSOR  OF  PRIN'CIPLES  AND 
PRACTICE,  AND  REGISTRAR,  DENVER  HOMOEOPATHIC  MEDICAL 
COLLEGE,   DENVER,   COLO. 

General  Considerations. — Diseases  of  the  spinal 
cord  occur  infrequently  in  children,  and  unfortunately 
they  are  seldom  diagnosed  by  the  average  general 
practitioner  until  the  ravages  of  the  malady  have  be- 
come cognizable  even  to  the  laity.  The  most  fre- 
quent form  included  in  this  category  is  myelitis.  By 
this  is  meant  an  inflammation  of  the  spinal  cord. 
Charity -like,  this  term  is  used  to  cover  much;  it  indi- 
cates a  condition  possessing  many  phases,  whose 
nomenclature  is  oftentimes  quite  arbitrary, — the  lat- 
ter depending  upon  the  mode  of  attack,  the  part  of 
the  cord  involved,  the  predisposing  influences,  the 
exciting  causes,  the  course  of  the  disease  and  the 
duration  of  the  malady. 

Thus,  it  will  be  seen  that  we  may  have  to  consider 
the  acute,  subacute,  or  chronic  manifestations;  the 
transverse,  central,  annular,  diffuse,  focal,  or  dissemi- 
nated varieties;  the  interstitial  or  parenchymatous 
forms ;  the  syphilitic,  infectious,  secondary,  compress- 
ive, or  traumatic  sources.     From  this  it  may  be  in- 


DISEASES   OF    THE    SPINAL    CORD.  I15 

ferred,  that  the  symptomatology  of  myelitis  is  neces- 
sarily very  comprehensive  in  its  scope  and  character. 

Poliomyelitis  Anterior.  —  First  and  foremost 
among  these  conditions  is  poliomyelitis  anterior. 
This  occurs  most  frequently  in  the  first  three  years 
of  life.  It  may  be  primary,  or  it  may  be  secondary 
to  diseases  of  a  toxic  character.  Traumatism  may 
occasionally  induce  it.  It  occurs  more  frequently 
during  the  summer  months.  The  development  of 
this  phase  of  spinal  disease  is  sudden  and  acute.  Its 
course  soon  becomes  more  or  less  chronic.  A  prod- 
romal stage  of  several  days'  duration  is  sometimes 
seen,  which  is  characterized  by  fever  and  restlessness, 
though  it  may  be  ushered  in  suddenly  by  convulsions. 
After  the  initial  stage,  the  following  symptoms  are  to 
be  expected:  Unconsciousness,  often  lasting  many 
days ;  vomiting ;  intestinal  disturbance ;  bladder  com- 
plications ;  great  nervous  irritability,  which  may  sug- 
gest the  prodromata  of  a  number  of  diseases ;  tem- 
perature ranges  from  loo  degrees  to  102  degrees  F., 
sometimes  higher. 

The  prodromal  symptoms  may  be  absent,  and  a 
paralysis  will  suddenly  affect  the  extremities;  this 
soon  becomes  monoplegic.  Pain  in  the  affected  limb 
often  occurs  at  first.  The  motor  sphere  is  involved, 
while  that  of  sensation  remains  intact.  All  forms  of 
paralysis  may  occur, — paraplegia,  diplegia,  cross- 
paralysis,  paralysis  of  both  arms,  the  dorsal  muscles, 
and  those  of  the  abdomen,  and  even  hemiplegia; 
groups  of  muscles  are  attacked, — the  extensors,  ab- 
ductors, or  supinators. 

The  prodromal  symptoms  usually  pass  away  very 


Il6  PRESENT    STATUS    OF    PEDIATRICS. 

quickly,  the  usual  functions  are  carried  on,  the  gen- 
eral growth  continues,  and  mental  activity  is  unim- 
paired; the  tendon  reflexes  disappear  from  the  af- 
fected limbs;  at  its  height,  the  paralysis  remains 
stationary  from  two  to  four  weeks,  at  which  time  a 
gradual  improvement  begins ;  other  groups  are  then 
involved  in  the  same  way,  with  similar  results. 
These  various  groups  may  recover  entirely,  or  remain 
disorganized,  with  contractures  and  deformities.  A 
paralysis  affecting  the  gastrocnemii  and  posterior 
tibial  muscles  results  in  an  anterior  flexion,  and  the 
child  will  walk  upon  its  heel ;  if  the  anterior  muscles 
are  principally  affected,  talipes  equinus  results.  The 
deformity  will  always  depend  upon  the  group  of  mus- 
cles involved. 

Dislocation  of  the  joints  may  occur;  the  tissues  be- 
come flaccid ;  too  great  mobility  often  results ;  as  may 
be  seen  at  times  in  the  hip,  knee,  ankle,  shoulder,  or 
wrist. 

Muscular  atrophy  is  marked,  rapid,  and  extreme ; 
the  bones  are  arrested  in  growth ;  the  surface  tem- 
perature of  the  affected  part  is  lowered ;  its  circula- 
tion is  sluggish ;  it  is  cold,  relaxed,  and  lifeless ;  the 
implicated  muscles  respond  slowly,  or  not  at  all  to  the 
faradic  current. 

For  clinical  convenience,  the  disease  may  be  divided 
into  four  stages ;  invasion,  lasting  from  a  few  hours 
to  several  days,  characterized  by  local  tenderness, 
with  rapidly  developing  and  increasing  paralysis ;  a 
stationary  stage,  of  several  weeks'  duration;  a  period 
of  improvement,  lasting  several  months ;  permanent 
disability,  for  the  remainder  of  life. 


DISEASES    OF    THE    SPINAL    CORD.  Iiy 

Clinical  suggestions  will  be  found  at  the  close  of 
this  section,  in  conjunction  with  other  diseases  of  the 
cord.  This  method  has  been  adopted,  because  of  the 
wide  range  of  our  remedies,  as  well  as  the  peculiar 
relations  which  so  often  co-exist  between  the  different 
arbitrary  divisions  of  affections  of  the  spinal  cord. 

Acute  Myelitis,  or  acute  softening  of  the  cord, 
usually  develops  gradually,  unless  from  traumatic 
causes.  This  stage  may  be  from  a  few  hours  to  sev- 
eral months,  according  to  the  causative  conditions 
which  are  in  operation.  In  cases  developing  more 
slowly  there  are  prodromata;  temporary  weakness; 
tingling  sensations;  radiating  pains;  numbness  and 
weakness  in  the  legs ;  the  lower  extremities  become 
heavy  and  unmanageable ;  paralysis  soon  follows. 

During  the  first  week  the  temperature  rises,  but 
it  rarely  reaches  104  degrees  F.  ;  delirium  and  con- 
vulsions may  occur ;  the  reflexes  are  early  and  per- 
manently lost.  The  pain  will  vary  with  the  seat  of 
the  inflammation ;  if  the  posterior  roots  and  meninges 
are  involved,  pain  in  the  back  and  limbs  is  very  prom- 
inent and  excruciating.  A  girdle  sensation  and  zone 
of  hypersesthesia  about  the  abdomen  or  chest  may 
serve  to  indicate  the  upper  limit  of  the  disease.  The 
symptomatology  will  vary  according  to  the  location 
and  area  of  the  lesion. 

Below  the  affected  part,  and  depending  upon  the 
intensity  of  the  attack,  there  are  all  shades  of  sensa- 
tions, from  slight  numbness  to  complete  anaesthesia. 

In  some  cases  there  is  an  aching  sensation  in  the 
legs,  while  cramps  and  flexing  of  the  lower  limbs  is 
the  rule.     The  paralyzed  portions  have  at  first  an  in- 


Il8  PRESENT    STATUS    OF    PEDIATRICS. 

creased  temperature,  but  they  soon  become  sub- 
ijormal.  Sluggish  circulation  and  emaciation  follow, 
and  oedema  shows  itself  where  the  limbs  are  in  a 
pendant  position.  Bed-sores  quickly  develop,  and  are 
quite  intractable. 

Clinically  considered,  a  given  case,  suffering  from 
this  malady,  may  be  arrested  at  any  point,  from  which 
a  recovery  more  or  less  complete  may  follow.  It 
may  progress  from  bad  to  worse ;  the  formation  of 
bed-sores,  cystitis,  exhaustion,  death. 

Chronic  Myelitis  is  the  result  of  an  acute  attack, 
which  it  usually  follows.  Its  diagnosis  depends  upon 
the  following  significant  symptoms :  The  long  dura- 
tion of  the  malady  with  the  history  of  an  acute  stage ; 
bladder  complications ;  intestinal  involvement ;  para- 
plegic disturbance  of  sensation;  motor  deficiency; 
continued  wasting;  absence  of  pupillary  symptoms; 
lightning  pains ;  inco-ordination ;  rigidity  of  the 
limbs ;  increased  reflexes ;  marked  contractures ;  old 
bed-sores. 

Landry's  Paralysis,  or  the  acute  ascending  form 
of  paralysis,  is  occasionally  diagnosed  in  children. 
It  follows  infectious  diseases,  exposure  to  wet  and 
cold,  traumatism,  and  syphilis.  It  presents  the  fol- 
lowing group  of  symptoms :  A  feeling  of  weakness 
begins  in  the  feet  and  legs  and  creeps  slowly  upwards 
and  becomes  more  pronounced  in  the  lower  levels  as 
the  disease  ascends.  In  the  course  of  a  few  days  the 
lower  extremities  are  completely  paralyzed  and  the 
weakness  has  involved  the  trunk  and  the  upper  ex- 
tremities; the  breathing  is  impaired;  deglutition  is 
difficult ;  every  voluntary  muscle  below  the  face  may 


DISEASES    OF    THE    SPINAL    CORD.  II9 

be  involved  and  rendered  completely  useless;  the 
sphincters  are  7iot  relaxed;  tendon  and  superficial 
reflexes  are  usually  present;  sensation  is  not  per- 
verted. Recovery  from  this  disease  it  slow  and  in 
the  reverse  order  of  its  development. 

Syring'Omyelia  has  been  defined  as  a  disease  of 
the  spinal  cord  which  is  characterized  by  a  growth  of 
gliomatous  tissue  in  the  gray  matter;  this  breaks 
down  and  forms  a  cavity.  Traumatism,  infectious 
diseases,  and  exposure  to  cold  are  among  the  exciting 
causes.  The  symptoms  depend  upon  the  point  af- 
fected, and  they  may  be  defined  thus:  Analgesia; 
thermo-anaesthesia;  the  type  is  hemiplegic,  and  at 
times  monoplegic;  progressive  muscular  atrophy; 
loss  of  power ;  tremor  in  the  hands  and  fingers ;  tro- 
phic lesions  of  the  skin  produce  hypertrophies,  cal- 
losities, ulcerations,  eruptions,  maculae,  and  glossy 
spots;  the  nails  become  thickened,  ridged,  and  fall 
off  ;  whitlows ;  abscesses ;  fragilities  of  the  bony 
structures ;  deviation  of  the  spine ;  scoliosis ;  kypho- 
sis ;  lordosis ;  the  extremities  are  cold,  with  alternate 
burning  sensations;  persistence  of  lines  or  depres- 
sions drawn  upon  the  skin ;  the  knee-jerk  is  exag- 
gerated ;  ankle-clonus  is  present ;  the  gait  is  feeble ; 
ataxia  may  be  present;  also,  swaying  with  closed 
eyes.  The  course  is  slow,  and  the  termination  is  un- 
favorable. 

Hereditary  Ataxia  usually  begins  in  the  legs,  ac- 
companied by  nystagmus,  impaired  speech,  and  fol- 
lows a  slow  progressive  course.  It  is  characterized 
by  the  following  conditions :  Unsteadiness  upon  the 
feet;  awkwardness  and  clumsiness  in  walking;  the 


I20  PRESENT    STATUS    OF    PEDIATRICS. 

knee-jerk  disappears  early;  there  is  not  much  pain; 
muscular  power  is  reduced ;  the  patient  becomes  help- 
less ;  the  head  rolls  around  upon  the  shoulders ;  there 
are  tremors  and  choreic  movements ;  the  usual  facial 
expression  is  lost ;  the  jaw  drops ;  the  eyelids  become 
heavy  and  droop ;  there  is  an  appearance  of  apathy 
or  even  imbecility,  and  exhaustion. 

TREATMENT. 

General. — The  clause  referring  to  the  treatment 
may  be  prefaced  with  the  remark  that  medicines  do 
not  promise  much  benefit  in  this  class  of  cases  unless 
they  are  administered  in  accordance  with  the  princi- 
ples of  homoeopathy.  A  primary  desideratum  in  these 
conditions  is  the  securing  of  complete  rest, — rest  in 
body  and  mind.  In  the  great  majority  of  such  cases 
the  patient  should  be  put  to  bed  at  once,  placed  upon 
one  side,  or  upon  the  chest  or  abdomen,  and,  as  much 
as  possible,  prevented  from  lying  upon  the  back. 
The  food  and  drinks  must  be  carefully  adapted  to 
each  individual  case.  The  excretions  should  be 
closely  watched  and  judiciously  aided  if  necessary. 
Strict  cleanliness  must  be  observed.  In  many  cases, 
delicate  massage  and  light  hand-rubbing  will  accom- 
plish good  results.  Study  the  causes  of  the  trouble 
and  remove  them  if  possible.  It  should  ever  be  borne 
in  mind  that  whatever  tends  to  produce  a  healthy  tone 
of  the  individual  patient  and  to  increase  the  hopeful- 
ness of  his  surroundings  will  assist  more  or  less  di- 
rectly in  facilitating  the  cure. 

Medicinal. — In  the  earlier  stages  the  polychrests 
may  be  indicated ;  if  so,  and  they  are  properly  admin- 


DISEASES    OF    THE    SPINAL    CORD.  12 1 

istered,  the  trouble  may  be  much  modified,  thus  ren- 
dering mild  and  tractable  what  would  otherwise  be 
dangerously  obstinate.  The  following  remedies  may 
be  indicated  in  the  early  course  of  this  class  of  cases : 
Acovite^  belladoima^  gelscininuDi^  nux  vomica^  vera- 
truvi  viride,  ignatia^  arsenicuni^  etc.,  etc.  The  symp- 
toms should  be  carefully  collated,  the  case  individ- 
ualized, and  the  remedy  selected  independently  of  the 
nomenclature  as  applied  to  the  malady.  Use  any 
medicine  whose  totality  of  symptoms  is  analogous  to 
those  found  to  exist  in  any  prior  case.  Use  the  sin- 
gle remedy, — do  not  alternate.  Do  not  administer 
too  much  medicine — nor  too  little.  In  your  choice 
of  the  similimum,  be  as  "wise  as  serpents  and  as 
harmless  as  doves." 

Agaric  us  deserves  much  consideration;  its  pains 
are  bruised,  sprained,  stitching  and  tensive  sensa- 
tions ;  its  spinal  symptoms  are,  stitching,  deep-seated, 
burning,  and  aching  pains,  aggravated  by  stooping; 
soreness  to  the  touch;  flying  pains;  weakness  and 
stiffness. 

Aliuninmm  metalliciim — The  soles  of  the  feet  feel  as 
if  they  were  too  soft  and  swollen ;  the  heels  are  numb ; 
the  limbs  are  heavy  and  difficult  to  lift;  the  gait  is 
slow  and  staggering ;  inability  to  walk  in  the  dark  or 
with  the  eyes  closed ;  bruised  pain  in  the  back ;  burn- 
ing sensation  in  the  lower  vertebrae. 

Argenttun  nitriciun — For  a  staggering  gait;  ver- 
tigo; trembling;  tremulous  sensations;  general  de- 
bility ;  chorea-like  movements  of  the  limbs ;  transient 
blindness ;  sunken,  pale  countenance ;  sleeplessness. 

Calcarea  carbonica — For  pains  in  the  shoulders ;  loss 


122  PRESENT    STATUS    OF    PEDIATRICS. 

of  muscular  power ;  the  dorsal  muscles  become  atro- 
phied; the  lower  limbs  are  wasted;  there  is  quivering 
of  the  extremities ;  dimness  of  sight ;  cramps  in  the 
feet  and  legs ;  anorexia ;  constipation ;  great  nervous- 
ness. 

Cicuta — Vertigo  and  reeling;  frequent  jerks  in  the 
upper  portion  of  the  body ;  spasms  and  cramps  in  the 
nape  of  the  neck  and  spasmodic  throwing  of  the  head 
backward ;  hiccough ;  unconsciousness ;  spasms  with 
great  distortion  of  the  limbs. 

Cocnihis — The  legs  become  unwieldy,  they  are  lifted 
with  great  difficulty  and  dragged  along ;  the  hands 
lose  their  sensibility;  nervous  exhaustion;  profound 
weakness  of  the  extremities;  aching  in  the  limbs; 
the  extremities  fall  asleep ;  mental  depression. 

Colchiciun — Extreme  prostration ;  tendency  to  col- 
lapse ;  shifting,  shooting  pains ;  the  suffering  is  of  a 
paralytic  character ;  cramps ;  anxiety  and  strangury. 

Ctipriun  aceticiim — Numbness  and  lameness  in  the 
left  hand ;  the  left  foot  drags  when  walking ;  a  numb 
lameness  involves  the  left  sole  and  extends  gradually 
to  the  knee ;  standing  and  walking  becomes  difficult ; 
the  left  foot  and  leg  are  atrophied ;  sense  of  coldness 
in  the  left  foot ;  dull  pain  from  the  hip  to  the  knee. 

Eupatorium  perfoliatiirn — Aching  in  the  bones  and 
soreness  of  the  flesh ;  feeling  as  if  the  joints  were 
broken  or  dislocated. 

Hypericum — After  an  injury  ;  the  slightest  motion 
of  the  arms  or  neck  is  extremely  painful ;  the  cervical 
vertebrae  are  very  sensitive  to  the  touch ;  headache ; 
desire  for  warm  drinks. 

Niix  vojnica — Partial  paralysis  of  the  lower  limbs 


DISEASES    OF    THE    SPINAL    CORD.  1 23 

from  over  exertion  and  exposure ;  the  limbs  drag  and 
cannot  be  lifted  from  the  ground  when  walking ;  sen- 
sation impaired  in  the  legs ;  the  limbs  are  cold  and 
bluish;  constipation;  anorexia;  and  occipital  head- 
ache. 

Plumbum  metalliciim — For  tremor  of  the  right  arm 
during  voluntary  motion ;  the  arms  become  tremulous 
on  attempting  to  use  them,  with  weakness  and  numb- 
ness ;  the  tongue  trembles  when  being  protruded  or 
when  trying  to  talk ;  the  speech  is  hesitating  and  slow ; 
diplopia ;  dimness  of  vision ;  optic  neuritis. 

PJiysostigma — Tremors,  especially  from  psychic  or 
physical  disturbances  in  the  young ;  staggering  gait ; 
constriction  about  the  head  or  waist;  a  feeling  of 
weakness,  as  though  paralyzed,  passes  downward 
from  the  occiput  to  the  lower  limbs,  which  feel  as 
though  they  were  asleep. 

Phosphorus — After  exposure  to  cold  and  moisture ; 
in  connection  with  an  inflammatory  process  of  the  ver- 
tebrae; burning  pain  in  the  spine;  tenderness  at  the 
roots  of  the  spinal  nerves ;  dyspnoea ;  cough ;  feeble 
vision ;  vertigo ;  constipation,  with  narrow,  dry  stools ; 
anaesthesia  of  the  extremities. 

Picric  acid — Spasms  of  a  tonic  and  clonic  character ; 
the  legs  are  kept  widely  apart  when  the  patient  is 
standing;  he  looks  steadily  at  objects,  as  if  unable 
to  make  them  out ;  his  limbs  are  unable  to  support 
the  body. 

Rhododendron — Bruised  feeling;  symptoms  are 
greatly  aggravated  by  barometric  changes ;  sensitive- 
ness to  cold  winds ;  always  worse  before  a  storm  ;  and 
trembling  and  tottering. 


124  PRESENT    STATUS    OF    PEDIATRICS, 

Rhus  toxicodendron — After  infectious  diseases,  or 
from  exposure ;  from  cold  and  dampness ;  high  fever ; 
great  restlessness;  tingling  sensation  in  the  limbs; 
and  paralysis  of  the  extremities. 

Secale  cornutuni — May  be  of  benefit  where  there 
are  violent  pains  in  the  back,  especially  in  the  sacral 
region ;  anaesthesia  of  the  limbs ;  paralysis  of  the  ex- 
tremities with  convulsive  shocks  and  jerks;  painful 
contraction  of  the  flexor  muscles ;  and  paralysis  of 
the  bladder  and  rectum. 

Stilphur — Burning  and  tensive  pain  between  the 
scapulae ;  heat  on  the  top  of  the  head ;  palpitation  of 
the  heart;  sleeplessness;  this  is  of  great  benefit 
when  other  medicines  do  not  seem  to  act  well. 

Tarantula — Consequences  of  fright  and  rheuma- 
tism ;  trembling  in  the  left  hand,  aggravated  by  men- 
tal disturbances ;  after  a  fright ;  the  limbs  soon  be- 
come involved ;  intense  pain  at  night ;  rest  and  sleep 
are  broken ;  itching  and  crawling  in  the  lower  ex- 
tremities causes  the  patient  to  rise  and  move  about 
the  room ;  the  symptoms  are  worse  from  bathing, 
and  are  relieved  by  fresh  air ;  the  mentality  is  dimin- 
ished ;  inability  to  use  the  hands  because  of  tremb- 
ling;  anorexia;   constipation. 

Zincuvi  Dietalliciim — General  disturbance  of  the 
cerebro-spinal  system ;  delirium ;  neuralgias ;  spasms ; 
tremblings ;  hyperaesthesia ;  paralysis ;  it  affects  the 
nerve  structure  of  the  cord  itself;  spinal  irritation; 
lancinating  pains;  stiffness;  jerking  sensations;  inco- 
ordination ;  numbness ;  and  formication. 

Many  other  remedies  may  be  indicated  in  the 
course  of  the  various  conditions  arising  in  these  trou- 


DISEASES   OF    THE    SPINAL    CORD.  J2^ 

IdIcs,  in  consequence  of  which  the  Materia  Medica 
should  be  frequently  consulted  by  those  who  would 
achieve  the  utmost  possible  success  in  the  treatment 
of  this  group  of  diseases. 


126  PRESENT    STATUS    OF    PEDIATRICS. 


CHAPTER  VI. 


THORACIC  DISEASES. 

Trachea — Bronchi — Lungs — Pleur-'E. 

by  edward  r.  snader,  m.  d.,  lecturer  on  physical  diagnosis, 

HAHNEMANN    MEDICAL    COLLEGE;    CORRESPONDING    SECRETARY 
OF    PENNSYLVANIA    STATE    SOCIETY,    PHILADELPHIA,   PA. 

General  Considerations.— The  gross  pathology 
and  the  symptomatic  manifestations  of  disease  differ 
in  children  from  the  phenomena  found  in  adults  suf- 
fering from  the  same  thoracic  disorders.  The  diffi- 
culty of  obtaining  subjective  symptoms  is  readily 
understood;  and  the  so-called  objective  data  are  not 
so  classical  as  in  the  developed  adult,  for  various 
anatomical  and  physiological  reasons.  It  must  be  re- 
membered that  the  conditions  prevailing  at  birth  and 
during  the  subsequent  five  years  of  life  are  of  im- 
portance in  modifying  both  pathology  and  symptom- 
atology. The  bronchi  occupy  a  relatively  larger  area 
of  lung  space,  the  air-cell  cavities  are  smaller,  the 
vesicular  walls  thicker,  the  interstitial  tissue  is  greater 
in  amount,  the  epithleial  cells  occupying  the  air 
cells  more  numerous  relatively  (and  less  stable  and 
more  prone  to  rapid  cell-division)  than  in  adults. 
The  anatomical  differences,  and  the  tendency  to  rapid 
cell-division,  make  the  pulmonary  and  bronchial  mis- 


THORACIC    DISEASES.  127 

chiefs  of  children  of  graver  import  than  in  adults, 
other  things  being  equal. 

TRACHITIS  is  usually  an  affection  secondary  to  in- 
flammatory processes  in  the  air  passages  above  or 
below.  Atmospheric  conditions,  either  excessive 
heat"  or  cold,  or  dust,  may  produce  a  primary  attack. 
The  symptoms  are  irritating  cough,  which  gentle 
pressure  over  the  trachea  will  excite.  The  writer 
has  seen  many  so-called  bronchites  in  children  that 
were  really  trachites.  According  to  my  experience 
it  is  best  diagnosed  by  the  presence  of  very  large 
bubbling  sounds,  with  occasional  huge  dry  rales  heard 
only  over  the  sternum  and  between  the  scapula,  high 
up,  rales  being  heard  in  no  other  part  of  the  chest. 
I  have  observed  cases  which  I  thought  were  due  to  vio- 
lent, long-continued  spells  of  crying.  The  old  school 
douche  the  neck  with  cold  water  several  times  a  day 
to  remedy  the  ailment.  Antimoniiim  tartaricuni^  hy- 
drastis^  and  natriiin  muriaticum  are  of  service.  The 
prognosis  is,  of  course,  favorable  in  simple  trachitis. 

BRONCHITIS  (of  the  large  tubes)  may  be  either 
primary  or  secondary,  and  owing  to  the  anatomical 
peculiarity  in  children  of  the  prominence  of  the  capil- 
laries and  the  loose  connection  of  the  mucous  mem- 
brane to  the  muscular  walls  render  the  bronchial 
structure  specially  liable  to  congestion  and  inflamma- 
mation.  Sudden  atmospheric  changes,  dust,  etc., 
and  possibly  micro-organisms,  are  the  special  causes. 
Bronchitis  nearly  always  accompanies  measles,  per- 
tussis, la  grippe  especially,  and  sometimes  also  the  ex- 
anthemata, rhachitis  and  enteric  fever,  and  tuberculo- 
sis.    Pathologically,  bronchitis  gives  rise  primarily  to 


128  PRESENT    STATUS    OF    PEDIATRICS. 

congestion  of  the  mucous  membrane,  swelling  and  ar- 
rest of  secretion  of  the  mucous  glands,  with  enlarge- 
ment of  the  bronchial  glands.  Secondarily,  the  con- 
gestion diminishes,  then  occurs  hypersecretion  of  the 
mucous  glands,  desquamation  of  epithelial  cells,  and  an 
increased  formation  of  the  deeper  layers  of  the  same 
cells,  and  a  moderate  escape  of  white  blood  corpuscles 
and  occasionally  red  ones.  As  a  rule,  in  uncompli- 
cated cases,  all  the  processes  are  superficial.  Symp- 
tomatically  the  onset  of  bronchitis  differs  from  a  con- 
vulsion in  a  gradual  and  insidious  approach,  begin- 
ning very  generally  with  an  inflammation  of  the  naso- 
pharynx. The  temperatute  in  only  rare  instances 
goes  much  beyond  102  degrees  F.  Cough  is  the 
prominent  system,  dry  at  first,  and  loose  sounding- 
later.  The  disease  lasts  from  one  to  two  weeks  in 
uncomplicated  cases.  The  diagnosis  must  be  made 
by  exclusion.  The  physical  signs  are,  where  the  case 
is  uncomplicated  by  collapse  of  air  cells,  a  pre-ex- 
isting pulmonary  disease,  a  normal  percussion  note, 
with  dry  rales  of  large  size  at  first  and  large  moist 
rales  later.  The  rales  are  large,  unless  here  and  there 
the  smaller  tubes  are  involved,  when  a  few  sibilant 
and  small  moist  rales  may  be  heard.  The  rales  are 
best  heard  on  the  posterior  aspect  of  the  chest.  The 
prognosis  is  guarded  in  the  weak,  although  in  general 
favorable.  A  warm  room,  counter  irritation,  luine  of 
ipecacuanha  and  tincture  opii  camphorata  appears  to 
be  the  most  successful  treatment  of  the  old  school. 
Belladonna^  bryonia^  antinionium  tartaricuni,  anti- 
monium  iodatum,  stantium  iodatuni,  the  calcareas,  ipe- 
cacuanha, sulphur,  and  a  host  of  other  medicines  are 
useful  in  our  own  school. 


THORACIC    DISEASES.       •  I29 

Bronchitis  (of  the  small  tubes,  the  misnamed  cap- 
illary variety),  is  characterized  by  the  same  pathologi- 
cal changes  as  are  found  in  the  large-tubed  inflamma- 
tion, but  the  smaller  tubes,  in  addition  to  the  larger 
ones,  are  involved  in  a  much  more  intense  inflamma- 
tory process  than  in  the  ordinary  form.  Mechanical 
obstruction  from  the  products  of  the  bronchitis  alter 
the  symptomatology  of  the  two  diseases,  give  rise 
more  frequently  to  atelectasis  of  air  cells,  and  to 
broncho-pneumonia,  and  render  the  prognosis  ex- 
ceedingly bad,  although  not  invariably  hopeless  if 
the  general  strength  of  the  child  can  be  maintained. 
Temporary  small-tubed  bronchitis  occasionally  occurs 
during  the  progress  of  the  ordinary  form,  and  persists 
for  a  few  days,  the  case  then  progressing  as  in  the 
typical  large-tubed  variety.  The  symptoms  are  cough, 
rapid  respiration,  quick  pulse,  cyanosis,  dilatation  of 
the  alse  nasi,  and  an  unwillingness  on  the  part  of  the 
child  to  be  placed  in  a  recumbent  posture  (really,  a 
relative  orthopnoea).  Coma  and  convulsions  may 
close  the  scene.  The  physical  signs  are  a  normal 
percussion  note,  with  subcrepitant  and  sibilant  rales, 
together  with  large,  moist,  and  dry  sonorous  rales  dis- 
tributed generally  over  the  chest.  If  vicarious  em- 
physema complicate,  a  vesiculo-tympanitic  percussion 
sound  is  produced ;  if  collapse  of  air  cells,  dulness, 
persisting  only  while  the  atelectasis  lasts ;  if  broncho- 
pneumonia, dulness  on  percussion,  diminished  respi- 
ratory murmur  (or  bronchial  or  broncho-vesicular 
breathing),  localized  high-pitched  moist  rales,  all  per- 
sisting until  resolution  occurs.  The  subcrepitant  rale 
is  the  diagnostic  feature  of  small-tubed  involvement. 
10 


130  PRESENT    STATUS    OF    PEDIATRICS. 

Aromatic  Spirits  of  aniDionia^  stimulants,  emetics,  as 
ipecacuanha,  turpetJi  mineral,  and  apomorphia  are  used 
to  combat  the  disorder.  The  same  class  of  medicines 
are  useful  as  are  employed  in  the  large-tubed  variety, 
but  stibium  arsenicnni,  antimoniiim  iodatiim,  stan- 
num  iodatum,  ipecacnanJia,  and  kali  bichromicicm  and 
Pulsatilla  are  of  most  service.  Emetics  early  are  in- 
jurious; later,  when  cyanosis  and  drowsiness  super- 
vene and  the  cough  ceases,  emetics  must  be  used  to 
unload  the  obstructed  bronchi. 

Bronchitis  (chronic)  follows  occasionally  acute 
attacks,  but  sev^ere  pertussis,  rhachitis,  and  blood 
maladies  and  cardiac  disorders  are  specially  liable  to 
cause  it.  The  pathology  is  the  same  as  in  the  acute 
variety,  except  that  emphysema  and  dilated  bronchi, 
and  thickening  of  the  mucous  membranes,  are  liable 
to  complicate.  The  symptoms  are  the  same  as  in  the 
acute  variety,  some  cases  showing  anaemia,  debility, 
slight  febrile  rise,  and  emaciation,  while  others  are 
apparently  well,  save  the  cough.  A  dry  but  warm  cli- 
mate helps  idiopathic  cases.  Tonics  help  all  cases. 
The  treatment  must  be  specially  directed  to  the  un- 
derlying causes.  The  physical  signs  are  the  same  in 
uncomplicated  cases,  as  are  found  in  the  acute  form. 

Bronchitis  (fibrinous,  or  pseudo-membraneous)  is 
characterized  by  the  expectoration  or  vomiting  of  casts 
of  the  bronchi,  and  this  variety  is  rarely  diagnosable 
as  a  separate  form  until  the  casts  are  discovered.  Ate- 
lectasis is  specially  frequent.  Kali  bicJiromicum  and 
coccus  cacti  are  of  use. 

BRONCHO-PKEUMONIA  (catarrhal  pneumonia, 
lobular  pneumonia,  insufflative  pneumonia,  peribron- 


THORACIC    DISEASES.  I3I 

chitis)  is  especially  liable  to  occur  in  the  young,  either 
acutely  or  chronically,  because  of  the  embryonic  type 
of  lung  tissue.  It  is  frequently  followed  by  or  as- 
sociated with  tuberculosis,  and  in  its  origin  it  may  be 
general  or  otherwise.  It  follows  the  ordinary  forms  of 
bronchial  inflammation,  due  to  atmospheric  changes, 
but  is  especially  prone  to  complicate  the  exanthemata, 
more  particularly  measles,  scarlet  fever,  and  pertussis 
and  diphtheria.  Those  debilitated  by  previous  illness 
or  constitutional  dyscrasiae  are  its  especial  victims. 

Patholog'y. — Broncho-pneumonia  is  characterized 
by  an  inflammation  of  the  walls  of  the  terminal  bronchi 
and  the  surrounding  and  end  alveoli.  Consolidations 
are  formed  in  various  parts  of  the  lung,  distributed 
rather  irregularly  as  a  rule,  and  the  involvement  may 
not  only  be  lobular,  but  exceptionally  may  be  so  ex- 
tensive as  to  involve  a  lobe.  The  solidification  is 
produced  by  the  inflam'matory  products,  plus  prolifer- 
ated epithelial  cells,  pus  corpuscles,  red  corpuscles, 
and  somtimes  a  small  quantity  of  fibrin.  Dilatation  of 
the  bronchi,  emphysema,  and  fibrosis  occur  as  conse- 
quences and  sequences  of  the  semi-bronchial  inflam- 
matory process.  In  the  immediate  vicinity  of  act> 
ive  lesions  the  unaffected  portions  of  lung  are  con- 
gested. Both  absorption  and  resolution  of  the  pro- 
liferated cells  is  difficult,  much  more  so  than  is  a 
purely  fibrinous  exudate,  and  consequently  the  re- 
storative process  is  imperfectly  or  not  at  all  accom- 
plished. 

Symptomatology. — The  symptoms  vary  much, 
depending  upon  the  severity  of  the  attack,  the  amount 
of  lung  tissue  involved,  and  the  presence  of  compli- 


132  PRESENT    STATUS    OF    PEDIATRICS. 

cations.  In  severe  diseases  the  symptoms  of  broncho- 
pneumonia are  obscured  by  what  is  apt  to  be  con- 
sidered to  be  the  major  disorder.  Cough,  respirations 
more  rapid  than  the  degree  of  fever  warrants,  and  in- 
creased elevations  of  temperature,  should  lead  to  a  phy- 
sical exploration  of  the  chest  in  diseases  likely  to  give 
rise  to  catarrhal  inflammation  of  the  bronchial  mucous 
membranes  and  lung  parenchyma.  When  the  disease 
is  well  marked,  fever,  rapid  respirations,  quick  pulse, 
dilated  alse  nasi,  cyanosis,  drowsiness  or  wakefulness, 
and  a  painful  cough  are  prominent.  Sometimes  there 
occurs  a  pause  after  inspiration,  the  following  expira- 
tion being  a  moan.  This  symptom  occurs,  however, 
in  other  diseases  where  respiration  is  painful.  The 
disease  usually  ends  by  lysis,  and  does  not  pursue  any 
very  definite  course. 

The  physical  sig'ns  are  the  rales,  both  large  and 
small,  and  moist  and  dry,  of  the  accompanying  bron- 
chitis ;  dulness  on  light  percussion  in  spots  of  varying 
size,  if  the  lesion  be  large  enough  to  be  determined 
by  physical  exploration ;  broncho-vesicular  or  bron- 
chial breathing,  increased  vocal  resonance  or  bron- 
chophony. Sometimes  over  affected  areas  the  respira- 
tory murmur  is  suppressed,  and  the  rales  heard  are 
high-pitched.  If  collapse  occur  the  signs  of  this  con- 
dition are  added;  and  this  is  also  true  of  an  extensive 
vicarious  emphysema. 

Prog'nosis  is  guarded.  Fulminant  cases  die  in  three 
or  four  days.  If  the  temperature  remains  high  after 
the  second  week,  the  outlook  is  gloomy.  Death  in 
many  cases  results  from  exhaustion. 

Treatment. — The  treatment  consists  in  judicious 


THORACIC    DISEASES.  ^     1 33 

nursing,  a  warm  room,  ventilation,  stimulants,  warm 
baths,  warm  wet  packs,  and  oxygen  inhalations  are 
employed,  and  the  position  of  the  child  changed  often. 
Cardiac  stimulants  may  be  needed  during  attacks  of 
cyanosis.  Antimonium  tartaricum^  antinioniiivi  ioda- 
tum^  antini07iiuni  arseiiiciun^  stannnui  iodatiim^  ipe- 
cacuanha^ kali  bicJironiicuni^  pJwsphorus,  and  bryonia 
are  useful  medicines. 

LOBAR  PNEUMONIA  (croupous,  fibrinous,  pneu- 
monic fever)  is  an  acute  self-limited  lung  manifesta- 
tion of  a  disease  possessing  many  of  the  phenomena 
of  the  infectious  group. 

Causes. — The  diplococcus  pneumoniae  is  the  de- 
termining, and  sudden  atmospheric  changes,  particu- 
larly cold,  the  exciting,  cause  of  croupous  pneumonia. 

Pathology. — Lobar  pneumonia  is  an  acute  exuda- 
tive inflammation  which  preferably  and  progressively 
involves  a  whole  lobe,  the  larger  part  of  one  lung, 
and  occasionally  portions  of  both  lungs.  The  stages 
of  congestion,  red  hepatization,  gray  hepatization, 
and  resolution  occur  in  the  child  very  much  as  they 
do  in  the  adult.  In  the  congestive  stage  the  affected 
portion  of  the  lung  parenchyma  is  hyperaemic  and 
oedematous,  and  the  air  cells  contain  fibrin,  pus,  granu- 
lar matter,  red  blood  cells  and  epithelial  cells,  the  epi- 
thelium of  the  air  cells  being  swollen  and  the  capil- 
laries fairly  filled  with  white  blood  corpuscles.  The 
exudate  becomes  decolorized  (gray  hepatization),  de- 
generates, and  is  generally  readily  absorbed. 

Symptomatolog'y . — Lobar  pneumonia  is  generally 
ushered  in  suddenly  by  vomiting,  convulsion,  or  no- 
ticeable fever.     Pain  soon  follows,  generally  referred 


134  PRESENT    STATUS   OF    PEDIATRICC 

by  the  unknowing  little  one  to  the  abdomen.  Painful 
cough  is  a  common  symptom,  but  may  be  absent  early. 
There  is  rarely  any  of  the  rust-colored  expectoration 
in  children  under  eight  years.  Delirium  and  stupor 
are  sometimes  so  marked  that  with  the  involuntary 
muscular  movements  of  the  head  and  body  and  in- 
voluntary urination  and  faeces  may  simulate  some 
form  of  meningitis.  Inflammation  of  the  brain  me- 
ninges sometimes  actually  occurs.  Pulse  and  respira- 
tion rales  are  both  increased,  the  latter  more  than  the 
former.  The  temperature  is  high,  104  degrees  or  105 
degrees  F.  The  disease  ends  suddenly,  and  may,  and 
often  does,  give  rise  to  great  prostration  and  even 
collapse.  The  disease  often,  however,  ends  by  lysis 
in  children  under  three. 

The  physical  signs  over  the  implicated  lobe  are 
dulness  and  percussion  (sometimes  tympanitic,  par- 
ticularly if  the  abdomen  is  distended),  bronchial 
breathing  (bronchophony),  if  the  consolidation  be 
complete,  and  if  incomplete,  the  signs  indicating  a 
lesser  degree  of  solidification.  The  fine,  dry  crack- 
ling rale  (the  crepitant)  is  only  occasionally  observed. 
In  the  resolution  stage  subcrepitant  rales  are  heard. 
The  limg  generally  commences  to  clear  up  as  soon  as 
defervescence  occurs,  but  the  process  of  absorption 
may  be  delayed. 

The  prog'nosis,  in  general,  is  good.  The  treatment 
is  mainly  expectant.  Stimulants  may  be  used  from 
the  outset  in  the  debilitated  or  very  young.  Collapse 
must  be  combated  by  warmth  and  stimulation,  the 
latter  per  oram  or  per  rectum.  Acofiite,  belladoufia, 
bryonia^  fcrriini  pJwsphoriciLDi^  snlpJnir^  pJwspJiorits, 


THORACIC    DISEASES.  135 

kali  bicliromicitm^  iodine^  ipecacuanha^  arsenic^  and  the 
a^itimonies  are  very  useful. 

PULMONARY  TUBERCULOSIS  is  an  affection  in 
which  certain  lesions  are  said  to  be  produced  by  the 
bacillus  tuberculosis.  The  bacilli  gain  entrance  into 
the  body  by  inspiration  or  being  swallowed. 

Patholog'y. — The  pathological  lesions  are  numer- 
ous, and  the  same  as  occurs  in  adults.  The  apices 
are  rarely  first  affected,  as  in  older  persons.  The 
lymph  glands  are  first  attacked,  as  a  rule,  and  after 
tuberculization,  break  down,  invading  the  lungs. 
Acute  tubercular  broncho-pneumonia  is  one  form, 
and  chronic  tuberculosis  of  the  lungs  another.  The 
special  features  of  the  broncho- pneumonic  form  are 
the  peribronchitis,  the  tubercular  features  being 
caseation  and  necrosis  of  the  consolidations,  together 
with  the  presence  of  the  bacilli. 

Age. — The  disease  develops  especially  from  the 
sixth  month  to  the  fifth  year,  and  may  follow  measles, 
pertussis,  diphtheria,  scarlatina,  and  tubercular  pro- 
cesses in  other  parts  of  the  body. 

Symptomatolog'y. — The  symptoms  are  cough  (ex- 
pectoration, if"  the  patient  is  old  enough  and  knows 
how),  fever,  emaciation,  night  sweats,  and  the  sys- 
temic symptoms  of  the  accompanying  fever  and  in- 
fection. 

PPOgnosiS. — The  prognosis  is  invariably  grave. 

The  physical  sig'ns  are  more  likely  to  be  found 
posteriorly,  between  the  scapulae  and  in  the  lower 
lobes,  but  no  portion  of  the  chest  is  exempt.  Dul- 
ness  on  percussion,  bronchial  breathing,  increased 
vocal  resonance,  and  rales  localized  at  the  seat  of 


136  PRESENT    STATUS    OF    PEDIATRICS. 

lesion,  or  general  if  the  accompanying  bronchitis  is 
universal. 

The  treatment  is  a  tonic  one,  cod  liver  oil,  hypo- 
phosphites^ioTQed  feeding.  Arsenic, arseniciun  iodatuui, 
stanniim  iodatiim,  sulphur^  baptisia,  and  iodine  are 
somewhat  helpful.  Climate  is  of  more  service  than 
drugs  or  hygiene. 

ASTHMA  is  rare  in  infants,  but  not  uncommon  in 
childhood.  It  is  best  defined  as  a  neurosis  of  the 
pneumogastric  nerve,  characterized  by  paroxysmal 
dyspnoea,  induced  by  varying  conditions,  determined 
by  individual  idiosyncrasy. 

The  patholog'y  is  unknown,  but  is  most  rationally 
conceived  to  be  a  tonic  spasm  of  the  bronchial  mus- 
cular fibers,  leading  to  a  temporary  narrowing  of  the 
lumen  of  the  tubes,  and  consequent  difficult  respira- 
tion. 

Symptoms  are  sudden  shortness  of  breath,  partic- 
ularly at  night,  causing,  in  severe  cases,  orthopnoea, 
with  anxiety,  restlessness,  and  wheezing,  the  parox- 
ysm ending,  after  a  variable  interval,  in  apparent 
health. 

The  prog'nosis  as  to  the  attack  is  favorable. 
Many  attacks  are  accompanied  by  chronic  bronchitis. 
Emphysema  often  results. 

The  physical  Sig'ns  are  a  vesiculo-tympanitic  note 
on  percussion,  and  an  abundance  of  sibilant  and  so- 
norous rales  all  over  the  chest. 

Treatment  is  to  remove  all  diseases  of  the  bronchi 
and  naso-pharynx,  as  rhinitis,  enlarged  tonsils,  ad- 
enoid growths,  etc.  Antispasmodics  are  used  to  con- 
trol the  paroxysms,  as  belladonna  and  lobelia,  hydrate 


THORACIC    DISEASES.  137 

of  chloral  and  morphine.  Iodide  of  potassium  is  of 
service.  The  inhalation  of  the  fumes  of  potassium 
nitrate  is  the  most  common  procedure.  Bellado7ina^ 
lobelia^  ipecaciianJia^  arsefiic^  kali  carboniciim,  sani- 
biiciis,  nux,  stramonium,  hyoscyamus,  and  many  other 
drugs  have  proven  effective. 

DISEASES  OF  THE  PLEURA. 

PLEURITIS  (pleurisy)  is  an  acute  or  chronic  in- 
flammation of  the  pleural  membrane,  which  may  be 
dry,  or,  as  is  most  frequently  the  case,  accompanied 
by  a  serous,  sero-purulent,  or  purulent  effusion.  The 
disease  is  much  more  frequent  in  children  than  is 
generally  supposed,  and  the  effusion  is  more  apt  to  be 
purulent  in  children  than  in  adults.  The  pleural  affec- 
tion may  be  primary,  secondary,  or  complicating,  and 
seems  to  follow  all  kinds  of  exposure  and  infection 
by  all  sorts  of  micro-organisms. 

Pathology. — Pleuritis  is  generally  an  unilateral 
disease,  characterized  first  by  an  exudate  of  fibrin, 
followed  by  liquid,  and  subsequently,  if  the  fluid  be 
absorbed  or  removed,  by  adhesion  of  opposing  mem- 
branes, sometimes  leading  to  obliteration  of  the  pleu- 
ral cavity. 

The  symptoms  are,  in  general,  a  sudden  onset, 
restlessness,  and  even  pain  (generally  referred  to  the 
abdomen),  vshort,  dry,  painful  cough,  anorexia,  vom- 
iting, diarrhoea.  When  effusion  is  complete  the  pain 
lessens,  the  dyspnoea  is  less  severe,  the  temperature 
remits  in  the  morning,  the  child,  if  the  effusion  be 
large,  prefers  the  affected  side.  If  the  case  runs  be- 
yond ten  days  before  absorption  is  complete  it  is 
likely  to  become  chronic. 


138  PRESENT    STATUS    OF    PEDIATRICS. 

The  physical  Sig'ns  in  the  dry  stage  are  often  dif- 
ficult to  detect,  inasmuch  as  the  pleuritic  rub  is  not 
always  heard,  but  there  is  tenderness  on  the  affected 
side  to  palpation,  percussion,  and  compression.  When 
effusion  has  taken  place,  dulness  on  percussion,  di- 
minished respiration,  or  distant  bronchial  breathing, 
and  sometimes  a  decrease  of  the  vocal  resonance,  and 
fremitus,  together  with  displacement  of  the  heart  if 
the  effusion  be  great.  Variations  in  fremitus  and  the 
resonance  of  the  voice  are  less  inarked  in  the  pleuri- 
tis  of  children  than  in  adults.  Displacement  of  the 
heart,  liver,  and  spleen,  and  bulging  of  the  chest 
walls,  obliteration  of  intercostal  spaces,  speaks  for 
the  presence  of  fluid.  The  dulness  on  percussion  can 
in  some  instances  be  made  to  change  its  level,  and  as- 
sists thus  in  distinguishing  pleuritis  from  lung  affec- 
tions, for  which  it  might  be  mistaken.  Aspiration  is 
not  a  conclusive  means  of  diagnosis;  fracture  has 
been  made,  and  no  fluid  has  followed  where  fluid 
really  existed. 

The  prognosis  is,  in  general,  good,  if  the  effusion 
be  simple  serum  and  the  fluid  is  not  effused  too  rap- 
idly and  does  not  greatly  displace  the  heart. 

The  treatment  early  is  to  relieve  pain  by  a  flan- 
nel bandage,  tinctura  opii  campJiorata.  Later,  aspi- 
ration, if  necessary  to  remove  intra-thoracic  pressure 
or  to  assist  absorption.  SulpJiur^  bryonia^  arsenicum 
iodatiun^  apis^  silicea^  and  apocyniuji  are  all  useful 
medicines.  If  aspiration  is  necessary  it  is  best  per- 
formed, in  general,  in  the  fourth  or  fifth  interspace, 
in  or  a  little  back  of  the  axillary  line. 

PURULENT  PLEURITIS  (empyema)  is  a  purulent 


THORACIC    DISEASES.  1 39 

collection  of  fluid  in  the  pleural  cavity,  derived  from 
a  primary  inflammation  therein,  or  from  the  rupture 
of  a  purulent  fluid  into  the  sac  from  some  one  of  the 
adjacent  or  surrounding  organs.  Pus  as  an  effusion 
is  much  more  frequent  up  to  four  years  than  is  a  ser- 
ous fluid. 

The  symptoms  are  the  same  as  those  found  in  a 
simple  serous  effusion.  The  temperature  is  no  defi- 
nite guide.  CEdema.  of  the  chest  walls  suggests  em- 
pyema, as  do  symptoms  indicating  great  gravity  of 
the  disease  process,  but  the  only  positive  differentia- 
tion is  to  be  made  by  aspiration  or  the  introduction 
of  a  big  lumened  needle  of  the  hypodermic  syringe 
and  the  macro  and  sometimes  microscopic  examina- 
tion of  the  fluid  thus  obtained. 

The  physical  Sig-ns  are  the  same  as  in  ordinary 
pleuritis  with  effusion ;  t.  e. ,  they  indicate  the  pres- 
ence of  fluid. 

Course. — The  disappearance  of  an  empyema  with- 
out surgical  interference  or  the  imperfect  surgery  of 
Nature  is  the  rarest  possible  occurrence  and  should 
never  be  expected.  The  pus  may  make  its  exit  by 
perforating  the  lungs  and  escape  into  bronchi,  form- 
ing a  pneumo-pyo-thorax ;  it  may  break  through  the 
chest  Ayalls,  preferably  in  the  region  of  the  fifth  in- 
tercostal space  (I  have  seen  two  cases  where  "spon- 
taneous" perforation  occurred  in  the  second  left  in- 
tercostal space — a  most  disadvantageous  position  for 
drainage) ;  it  may  ulcerate  through  the  diaphragm  and 
set  up  a  fatal  peritonitis,  or  in  fact  break  into  any 
organ  near  by  that  favoring  factors  permit.  When 
Nature  attempts  the  evacuation  (and  sometimes,  too, 


■140  PRESENT    STATUS    OF    PEDIATRICS. 

when  it  accomplishes  it)  of  the  pus,  great  deformity 
of  the  chest  results  and  extensive  adhesions  are 
formed. 

The  treatment  is  essentially  that  of  aspiration, 
as  frequently  as  is  necessary,  a  resection  of  the  ribs 
if  the  case  does  not  yield  to  repeated  tappings.  Tonic 
treatment  is  indicated,  the  calcareas  the  arseniates^ 
silicea,  hepar  siilphuris^  fluoric  acid^  sulplmr,  and  other 
medicines  are  sometimes  of  value. 

DISEASES  OF  THE  HEART  AND  PERICARDIUM. 

General  Considerations.— Cardiac  disease  in  the 
early  period  of  life,  in  some  respects,  differs  essen- 
tially from  the  same  disease  in  adults.  In  certain 
forms  in  children  there  is  much  greater  tendency  to 
recover  than  in  those  who  are  fully  developed.  Ow- 
ing to  the  undeveloped  condition  of  the  very  young, 
interference  with  growth  of  other  organs  and  the 
body  generally  occurs  in  consequence  of  cardiac  dis- 
eases ;  results  occur  that  it  would  be  impossible  for 
the  same  disease  to  produce  in  the  fully  developed 
adult.  The  soft  condition  of  the  ribs,  cartilages,  and 
sternum,  when  the  heart  enlarges,  permits  of  the 
formation  of  serious  chest  deformities,  encroaching 
on  the  lung  space,  and  destroys  the  possibility  of  the 
development  of  the  perfect  lung  equilibrium  found 
in  the  healthy.  The  blood  vessels  themselves  are 
much  more  rarely  affected  in  children  than  in  the 
older.  Aneurism  is  extremely  rare.  A  narrowing 
of  the  isthmus  aortse  is,  according  to  Rotch,  more 
common,  and  is  one  of  the  most  marked  of  the  con- 
genital defects  of  the  blood  vessels. 

CONGENITAL  DISEASES  usually  result  from  an 


THORACIC    DISEASES.  141 

interference  with  the  proper  development  of  the 
organ,  from  endocarditis,  or  from  both  combined. 
At  birth  the  great  points  of  failure  are  "Chq  foramen 
ovale  and  the  ductus  arteriosus.  Both  should  be  closed 
by  the  tenth  day.  Where  the  heart  has  been  defect- 
ively developed  during  intra-uterine  life,  the  chief 
malformations  are  an  open  ventricular  septum,  a 
transposition  of  the  great  vessels,  and  valvular  and 
orificial  deformities.  The  most  common  results  of 
foetal  endocarditis  are  stenosis  of  the  pulmonary 
artery,  narrowing  of  the  conus  arteriosus^  and  distor- 
tion of  the  tricuspid  and  other  valves  and  orifices. 
Foetal  endocarditis  is,  according  to  Osier,  rarely  ver- 
rucose,  the  variety  being  sclerotic. 

The  symptoms  of  congenital  heart  disease  are 
sometimes  indefinite  for  some  time  after  birth,  but  in 
a  large  proportion  of  cases  evidences  of  embarrass- 
ment of  the  circulation  are  manifest.  It  is  true,  how- 
ever, that  grave  cardiac  disease  may  exist  without 
signs  or  symptoms.  Cyanosis  and  attacks  of  short- 
ness of  breath  (sometimes  almost  suffocative),  and 
wasting,  are  the  prominent  symptomatic  guides. 
Later,  the  finger  ends  become  clubbed,  the  nails  blue, 
the  skin  cool. 

The  physical  signs  are  seldom  sufficient  to  deter- 
mine the  exact  form  of  deformity.  There  is  gener- 
ally decided  pulsation  in  the  praecordia,  with  bulging 
of  the  cardiac  region,  and,  if  the  heart  be  much  en- 
larged, the  area  of  cardiac  dulness  augmented.  Dif- 
fuse cardiac  murmurs  may  sometimes  be  heard  over 
the  whole  chest,  are  commonly  located  with  the  first 
sound  of  the  heart,  and  are  most  intense  towards  the 
tipper  part  of  the  sternum. 


142  PRESENT    STATUS   OF    PEDIATRICS. 

Prognosis. — Children  with  congenital  heart  disease 
are  apt  to  die  suddenly.  Lesions  of  the  pulmonary 
artery,  if  associated  with  a  safety-valve  ventricular 
septum,  may  permit  of  a  number  of  years  of  life, 
while  an  open  foramen  ovale  without  other  lesion, 
allows  of  life  for  years.  Transposition  of  the  main 
arterial  trunks  permits  of  but  a  short  life.  Death 
results  suddenly,  commonly  from  some  pulmonary 
affection,  hemorrhage,  or  tuberculosis. 

The  treatment  includes  freedom  from  excitement 
and  overexertion,  aromatic  spirits  of  ammonia  during 
pronounced  dyspnoea,  and  the  cardiac  tonics  when 
compensation  fails. 

Therapeutics. — Cactus^  lachesis^  arsemcum  ioda- 
tum,  rhiis  toxicodendron^  silicea^  and  sulpJinr  are  sug- 
gestive medicines. 

FUNCTIONAL  DISEASES  rarely,  if  ever,  occur 
until  the  later  years  of  life,  and  arise  from  anaemia  of 
the  nerve  centers  and  from  mal-feeding,  masturba- 
tion, and  cardiac  irritants,  such  as  tea  and  coffee. 

Pathologically  the  cardiac  muscle  may  be  slighfly 
weakened  and  a  minor  degree  of  possibly  transitory 
dilatation. 

While  symptoms  differ  in  individual  cases,  they  are 
in  the  main  palpitation,  weak  irregular  pulse,  attacks 
of  shortness  of  breath,  and  fainting,  and  occasionally 
haemic  murmurs.  If  the  cause  can  be  discovered 
and  removed,  a  cure  soon  results. 

Therapeutics. — Spigelia,  cactus,  digitalis,  kalmia, 
rJius,  aconite,  belladonna,  and  ferritin  are  good  reme- 
dies. 

ORGANIC  DISEASES  may  be  of  mechanical  or 


THORACIC    DISEASES.  143 

inflammatory  origin,  and  originate  primarily  or  sec- 
ondarily. Both  dilatation  and  hypertrophy  are  con- 
sidered mechanical. 

Causes. — Primary  dilatation  may  occur  at  puberty 
and  as  the  result  of  overexertion,  and  secondary  hy- 
pertrophy from  pericardial  and  pleuritic  adhesions, 
lung  consolidations,  pertussis  with  its  accompanying 
emphysema  and  atelectasis,  or  increased  blood  press- 
ure, as  from  renal  disease  or  aortic  stenosis  or  other 
valvular  lesions ;  while  among  the  inflammatory  dis- 
eases we  may  have  primary  or  secondary  endocardi- 
tis, and  myocarditis,  secondary  to  rheumatism,  the 
exanthemata,  diphtheria,  pneumonia,  enteric  fever, 
or  recurring  endocarditis  with  extension  to  the  mus- 
cular structure. 

Diagnosis  and  Physical  Signs. — In  the  pre-natal 
organic  heart  disease  the  right  side,  and  in  post-natal 
the  left  side,  is  the  more  likely  to  become  affected. 
Murmurs  indicating  lesions  are  apt  to  be  diffused  all 
over  the  chest  in  children,  and  do  not  travel  so  read- 
ily in  the  typical  paths  of  transmission  as  in  the  adult. 
In  children  alterations  in  the  rate  and  rhythm  are  less 
significant  than  in  similar  diseases  in  the  old.  Com- 
pensation is  more  readily  established  in  the  young. 
Pericardial  adhesions  are  much  more  frequent  in 
early  life.  A  just  appreciation  of  the  period  of  de- 
velopment is  of  first  importance  in  the  making  of 
diagnoses  of  disease  in  infants  and  children,  particu- 
larly in  diseases  affecting  the  heart  or  lungs.  The 
large  size  of  the  liver,  the  greater  proportionate  size 
of  the  heart  to  the  lung  in  the  earlier  years  of  child- 
hood, may  lead,  if  not  taken  into  account,  to  errors 


144  PRESENT    STATUS    OF    PEDIATRICS. 

in  diagnosis.  In  infants  the  dulness  in  the  superfi- 
cial cardiac  space  can  only  be  elicited  by  the  lightest 
percussion,  and  does  not  extend  over  an  area  much 
larger  than  the  point  of  the  pleximeter  finger,  while 
from  the  fourth  year  to  perhaps  the  ninth,  relative 
dulness  in  the  praecordia  is  more  marked  than  in  the 
adult,  and  the  superficial  cardiac  space  is  easily  out- 
lined. Other  things  being  proportionately  equal,  the 
liver  grows  more  after  the  adult  pattern  the  older  the 
child,  more  of  stomach  percussion  is  present,  and  the 
kidneys  posteriorly  and  the  top  portion  of  the  sternum 
become  relatively  lower. 

The  symptoms  indicating  organic  disease  are  not 
always  distinctive ;  in  fact,  the  physical  signs  may 
tell  you  of  the  presence  of  an  unsuspected  lesion, 
while  on  the  other  hand  cases  are  occasionally  found 
in  which  cardiac  symptoms  are  most  pronounced,  and 
yet  no  physical  signs  are  discoverable.  In  the  very 
young  the  impossibility  of  controlling  respiration  long 
enough  to  systematically  study  the  heart  sounds  and 
the  modifications  due  to  disease  may  account  for  some 
failures  to  discover  the  physical  evidences  of  organic 
disease.  Progressive  emaciation,  shortness  of  breath, 
cyanosis,  sometimes  dropsy,  and  sudden  alterations 
in  color,  or  distended  arteries  or  veins,  may  lead  to 
the  suspicion  of  the  presence  of  a  cardiac  affection. 

ENDOCARDITIS  is  the  most  common  cardiac  dis- 
ease of  children,  and  may  be  acute,  chronic,  recur- 
ring, and  primary  or  secondary. 

Cause. — Later  investigators  believe  that  all  endo- 
cardites  are  bacterial  in  origin,  there  being,  however, 
no  special  kind  necessary  to  produce  the  inflammatory 


THORACIC    DISEASES.  145 

process,  the  streptococcus  pyogenes,  staphylococcus 
pyogenes  aureus,  the  diplococcus  pneumoniae  having 
all  been  found.  It  does  not  seem  necessary,  therefore, 
to  distinguish  between  simple  and  ulcerative  (malig- 
nant) endocarditis,  there  being  simply  a  difference 
in  degree  of  the  malignant  nature  of  the  especial  or- 
ganism which  has  produced  the  disease  or  in  the  spe- 
cial vulnerability  of  the  attacked  individual. 

Patholog'ically  the  endocardium,  particularly 
about  the  valves,  is  swollen,  thickened,  and  the  sub- 
serous tissue  infiltrated.  Vegetations,  abrasions,  and 
new  connective  tissue  are  sometimes  noted.  In  some 
instances,  where  marked  cardiac  symptoms  and  signs 
have  been  present  during  life,  post-niorteni  shows  no 
lesions.  In  some  instances,  undoubtedly,  the  valves 
return  to  their  normal  condition. 

CHRONIC  ENDOCARDITIS  may  be  chronic  from 
the  onset,  or  succeed  an  acute  attack. 

Patholog'y. — The  aortic  and  mitral  valves  are  spe- 
cially liable  to  be  affected.  The  endocardium  may 
be  thickened  and  tense,  its  surface  smooth  or  covered 
with  small  vegetations  or  ridges,  or  an  overgrowth  of 
connective  tissue  cells  with  a  splitting  up  of  the  base- 
ment substance. 

Causes. — It  is  specially  liable  to  arise  from  pre- 
existing lesions,  from  rheumatism,  chorea,  scarlatina, 
and  other  exanthemata,  and  diphtheria.  Myocarditis 
may  be  present  also,  the  walls  of  the  heart  partici- 
pating in  the  inflammatory  change,  involving  prima- 
rily the  intestinal  tissue  and  blood  vessels,  the  mus- 
cular fibers  being  secondarily  affected  by  atrophic 
and  degenerative  changes. 
II 


146  PRESENT    STATUS    OF    PEDIATRICS, 

The  symptoms  of  endocarditis  are  often  as  obscure 
as  in  the  adult,  even  more  so,  frequently  being  alto- 
gether latent  in  infants  and  children.  When  arising 
secondarily  the  symptoms  are  especially  liable  to  be 
masked.  Palpitation,  dyspnoea,  cyanosis,  with  possi- 
bly vomiting,  and  irritative  cough  are  often,  however, 
pronounced,  and  are  especially  so  if  the  myocardium 
be  involved.  In  primary  cases  there  is  generally  a 
rise  of  temperature,  a  quickened,  sometimes  irregular 
and  weak  pulse,  palpitation,  dyspnoea,  and  praecordial 
distress.  If  dilatation  supervene,  and  it  sometimes 
does  even  in  acute  cases,  general  venous  stasis, 
enlargement  of  the  liver,  haemoptysis,  bronchitis, 
oedema  of  the  face,  legs,  and  arms,  and  anaemia  ap- 
pear.     Hemiplegia  from  embolism  may  occur. 

The  diag'nosis  is  usually  not  difficult,  although 
lesion  exceptionally  exists  without  murmurs.  The 
presence  of  a  murmur  at  the  point  of  attack  is  the 
diagnostic  feature.  The  murmur  grows  in  intensity 
daily  under  your  observation,  it  is  seldom  diffused  or 
transmitted  in  the  earlier  part  of  the  disease,  in  the 
experience  of  the  writer.  If  considerable  enlarge- 
ment of  the  heart  can  be  made  out,  with  a  distinct 
transmission  in  a  typical  direction,  as  in  old  compen- 
sated lesions  in  adults,  the  lesion  is  an  old  one,  or 
there  is  a  new  endocarditis.  In  long  continued  cases 
you  can  observe  the  compensatory  enlargement  gradu- 
ally taking  place.  Presystolic,  systolic,  or  diastolic 
thrill  can  sometimes  be  elicited  by  palpation,  at  the 
proper  valve  or  opening,  and  its  presence  is  just  as 
diagnostic  as  is  a  murmur  heard  during  auscultation. 
Of  course  there  may  be  several  lesions  at  the  same 


THORACIC    DISEASES.  147 

time,  with  their  corresponding  presystolic,  systolic, 
or  diastolic  murmurs  and  points  of  maximum  inten- 
sity. 

The  prognosis  in  acquired  endocarditis  is  favor- 
able. Death,  however,  may  occur  at  the  height  of 
the  attack  or  suddenly  from  heart  failure. 

The  treatment  is  rest  in  bed  and  the  control  of 
special  symptoms.  We  should  endeavor  to  accom- 
plish compensation  from  the  very  outset.  Sleep 
should  be  encouraged,  as  it  often  reduces  a  child's 
pulse  twenty  per  minute.  Baths  and  gentle  massage 
are  useful  in  regulating  the  cutaneous  circulation. 
Digitalis  and  iron  can  be  used,  and  nitro-glycerine 
controls  the  excessive  attacks  of  dyspnoea.  Aconite 
belladonna^  rJins^  spigelia^  kalniia^  lacJiesis^  kali  ear- 
boniciini^  sulphur^  silicea^  aiirttni^  digitalis^  and  bry- 
onia  are  useful  medicines. 

MYOCARDITIS,  when  it  occurs  in  connection  with 
endocarditis,  can  be  suspected  when  the  symptoms  of 
the  latter  disease  are  especially  violent  and  malignant. 

Diagnosis. — Occurring  without  valve  implication, 
myocarditis  may  be  judged  to  be  present  when  early 
or  late  in  adynamic  diseases,  the  first  sound  of  the 
heart  nearly  disappears,  the  pulse  thready,  and  symp- 
toms of  collapse  and  blood-poisoning  are  noted. 

The  prognosis  is  unfavorable  in  the  secondary 
cases,  although  less  so  than  in  the  adult. 

The  treatment  is  essentially  supporting  and 
tonic,  with  absolute  rest. 

DISEASES  OF  THE  PERICARDIUM. 

General  Considerations.— There  is  nothing  spe- 


148  PRESENT    STATUS    OF    PEDIATRICS. 

cially  distinctive  anatomically  in  a  child's  pericar- 
dium. The  amount  of  fluid  present,  however,  while 
variable,  is  probably  under  five  cubic  centimeters. 
Complete  or  partial  absence  of  the  pericardial  sac  has 
been  noted. 

Hydropericardium,  h^mopericardium,  and 
pericarditis  occur,  the  latter  much  more  frequently 
than  the  others,  and  is,  with  extreme  infrequency,  dry, 
being  specially  characterized  by  effusion  in  children. 
The  remains  of  pre-natal  pericariditis  have  been  ob- 
served in  post-mortems  made  in  infants  who  died  a 
fe^\'^  hours  after  birth. 

Etiolog'ically  a  number  of  micro-organisms  give 
rise  to  pericardial  inflammation,  the  m.icrococus 
lanceolatus  more  often  than  other  varieties.  Cases 
in  infants  follow  sepsis  from  the  cord ;  periostitis, 
ostitis,  traumatism,  rheumatism,  pneumonia,  pleurisy, 
the  exanthemata,  especially  scarlet  fever,  and  tuber- 
culosis have  causative  relationships. 

Pathologically  pericarditis  may  be  circumscribed 
or  diffused.  The  effusion  may  be  sero-fibrinous, 
hemorrhagic,  or  purulent ;  in  fact,  it  is  more  apt  to  be 
purulent  in  children  than  in  adults.  An  effusion  tinged 
with  blood  is  not  uncommon,  and  is  not  so  significant 
of  tuberculosis  as  in  the  adult,  although  a  pro- 
nouncedly hemorrhagic  fluid  usually  has  the  same 
significance  as  in  the  older.  The  pericardites  may  be 
acute,  chronic,  primary,  or  secondary. 

The  subjective  symptoms  in  infancy  and  child- 
hood are  of  the  vaguest  sort,  are  often  latent,  and 
where  pronounced  symptoms  are  present  they  are  of 
the  general  kind  and  refer  as  much  to  the  heart  and 


THORACIC    DISEASES.  149 

circulation  as  to  the  pericardium.  Pain  is  difficult  to 
locate  and  palpitation  and  irregularity  are  so  common 
in  general  diseases  affecting  children  that  it  is  not 
possible  to  formulate  definite  symptoms  as  character- 
istic of  the  outset.  Dyspnoea,  orthopnoea,  possibly 
dysphagia  and  slight  cyanosis,  and  palpitation  are  sig- 
nificant of  considerable  effusion. 

The  physical  signs,  in  typical  carses,  without  ad- 
hesion, and  with  the  friction  sound  present  and  the 
typical  area  of  dulness,  are  easy  of  diagnosis ;  but, 
owing  to  the  varying  degree  of  lung  elasticity,  the 
presence  of  thoracic  or  liver  disease,  together  with 
the  fact  that  the  apex  beat  is  higher  up  and  not  so 
frequent'ly  displaced  as  in  the  adult,  and  the  heart 
sounds  are  not  muffled  and  distant,  at  times  makes 
the  diagnosis  a  most  difficult  one.  If  adhesions  have 
occurred,  destroying  the  typical  dulness  of  effusion, 
the  problem  is  still  more  doubtful.  The  chief  disor- 
der from  which  it  must  be  separated  ;s  enlargement 
of  the  heart,  and  more  especially  dilatation.  Here 
the  main  distinguishing  sign  is  found  by  percussion. 
Enlarged  heart  does  not  extend  its  dulness  so  far  to 
the  right  as  does  effusion.  When  there  is  fluid  in  the 
pericardial  sac  the  dulness  is  noticed  to  the  right,  and 
is  noticed  in  the  fifth  interspace;  in  enlarged  heart 
the  dulness  returns  to  the  sternum  at  about  the  fourth 
rib.  It  is  seldom  indeed,  if  ever,  from  the  observa- 
tions of  Rotch,  that  the  dulness  of  an  enlarged  heart 
implicates  and  includes  the  fifth  right  interspace. 

The  prognosis  in  infants  is  bad ;  the  cases  usually 
soon  end  fatally.  In  late  childhood  there  is  the  same 
tendency  to  recovery  as  in  adults.      One  of  the  least 


150  PRESENT    STATUS    OF    PEDIATRICS. 

favorable  of  sequences  or  complications  is  the  adhesion 
of  the  two  layers  of  the  pericardium  (making  the 
diagnosis  especially  difficult),  which  may  paralyze  the 
cardiac  muscle,  or  from  the  resulting  stasis  of  blood 
may  lead  to  extensive  dropsy. 

Symptomatically  this  form'  of  cardiac  paralysis  is 
characterized  by  a  small,  frequent  pulse,  subnormal 
temperature,  slight  albuminuria,  and  oedema  of  the 
cheeks,  eye-lids,  and  lower  extremities. 

The  treatment  is  the  same  as  in  adults,  but  heart 
failure,  so  likely  to  occur  in  childhood,  is  to  be  espe- 
cially fought.  Absolute  physical  and  mental  rest 
must  be  enforced.  Early,  before  much  effusion  has 
taken  place,  cold  applied  to  the  praecordia  is  some- 
times helpful.  Digitalis^  and  the  free  use  of  stimu- 
lants, is  often  indicated.  If  the  symptoms  are  alarm- 
ing, paracentesis  of  the  pericardium  should  at  once 
be  performed,  and  not  in  the  left  fifth  intercostal 
space,  as  is  ordinarily  taught,  but  in  the  fifth  right 
intercostal  space  (according  to  Rotch).  Aconite^  bel- 
ladonna^ bryonia^  spigelia^  digitalis^  sulphnr^  kali  car- 
boniciini  and  iodatuni^  arsoiicnni  iodatnin,  kahnia,  and 
cactus  are  useful  medicines. 


DISEASES    OF    THE    DIGESTIVE    TRACT.  151 


CHAPTER  VII. 


DISEASES  OF  THE  DIGESTIVE  TRACT. 

KY  WM.  E.  LEONARD  M.  D.,  PROFESSOR  OF  MATERIA  MEDICA  AND 
THERAPEUTICS  IX  THE  HOMCEOPATHIC  MEDICAL  DEPARTMENT 
OF  TiIe  STATE  UNIVERSITY  OF  MINNESOTA,  MINNEAPOLIS,  MINN. 

AUTHORITIES. 
A  short  list  of  the  recent  books  upon  paedology  which  seem 
to  the  writer  to  treat  most  fully  upon  this  branch  of  the  subject 
is  herewith  appended  for  the  benefit  of  students: 
Keating's  Encyclopedia  of  the  Diseases  of  Children,  4  vols.    J. 

B.  Lippincott,  Philadelphia,  1890.     The  best  compendium 

in  the  English  language. 
Starr,  Louis.     The   American    Text-book   of   the  Diseases  of 

Children.     W.  B.  Saunders,  Philadelphia,  1895. 
Donkin,  H.  Brofau.    The  Diseases  of  Children  (Medical).    Wm. 

Wood&  Co.,  New  York,  1893. 
Fisher,  Chas.  E.     Handbook  of  the  Diseases  of  Children  and 

Their  Homoeopathic  Treatment.     The  Century  Pub.  Co., 

Chicago,  1895. 
Tooker,  R.  N.     The  Diseases  of  Children  and  Their  Homoeo- 
pathic Treatment.     Gross  &  Delbridge,  Chicago,  1895. 

The  field  of  practice  outlined  by  this  heading  com- 
prises at  least  one- half  the  ailments  of  infancy  and 
childhood,  and  can  by  no  means  be  fully  treated  in 
the  space  allotted  in  this  brochure.  The  writer  will 
attempt  simply  a  resiune  of  the  salient  and  practical 


152  PRESENT    STATUS    OF    PEDIATRICS. 

features  of  the  causation,  symptomatology,  and  treat- 
ment of  the  more  common  diseases. 

The  successful  management  of  the  infantile  dis- 
eases of  the  digestive  tract  implies  a  complete  prac- 
tical knowledge  of  the  diet  and  hygiene  of  that  period 
of  life,  and  withal  a  natural  love  for  children  as  well 
as  tact  in  their  management,  without  which  practice 
among  children  will  be  the  bane  rather  than  the  joy 
of  everyday  work. 

In  these  pages  the  natural  anatomical  order  will  be 
followed  in  the  classification : 

I.— MOUTH. 

Diseases  of  the  mouth  in  children  are  inflammatory, 
and,  with  the  single  and  rare  exception  of  gangrene, 
confined  to  the  mucous  inembrane. 

CATARRHAL  (Simple)  STOMATITIS,  or  ''nursing 
sore-mouth,"  is  a  simple  hypersemia  of  this  cavity, 
due  to  local  irritation,  or  not  uncommonly  it  is  the 
visible  evidence  of  a  disordered  stomach,  or  an  ac- 
companiment of  such  constitutional  diseases  as  tuber- 
culosis or  rickets,  or  of  any  of  the  eruptive  diseases. 
Because  this  form  of  stomatitis  is  most  common 
during  dentition,  that  process  itself  is  probably  a 
cause,  in  that  it  renders  the  infant  more  sensitive  to 
cold  or  wet  or  improper  hygiene  generally.  The 
mouth  is  reddened,  its  mucus  increased,  the  tongue 
.slightly  furred,  with  more  or  less  discomfort  in  the 
act  of  nursing,  and  only  occasional  bleeding.  There 
is  usually  only  slight  fever  and  no  general  disturb- 
ance, unless  the  affection  be  an  index  of  grave  con- 
stitutional disease.      The  removal   of  anv  souice  of 


DISEASES    OF    THE    DIGESTIVE    TRACT.  153 

irritation  to  the  mouth  in  nursing  or  food,  with  fre- 
quent washing  of  the  cavity  with  pure,  cool  water,  a 
decoction  of  marsJunallow  or  linseed^  or  borax  and 
glycerine^  generally  suffices  without  a  specific  remedy. 

ULCERATIVE  STOMATITIS.— Ulceration  of  the 
mouth  may  sometimes  follow  upon  catarrhal  stoma- 
titis, but  stomacace  or  "putrid  sore  mouth,"  the  af- 
fection usually  known  as  ulcerative  or  ulcerous 
stomatitis,  is  a  primary  form  of  more  intense  inflam- 
mation, resulting  in  extensive  ulceration  especially  of 
the  gums,  accompanied  by  much  fetor  of  the  breath ; 
occasionally  apparently  contagious,  and  by  some 
thought  to  be  dependent  upon  a  specific  germ,  al- 
though this  is  not  yet  established.  The  inflammation 
begins  with  small  white  or  yellowish  points  of  plastic 
exudation  and  ulceration  along  the  gums,  spreading 
irregularly  to  the  buccal  surface.  The  swelling  and 
the  grayish-pinky  sloughs  give  the  appearance  of  a 
deeper  ulceration  than  really  exists,  nor  does  this  form 
extend  to  involvement  of  the  bone,  except  occasion- 
ally on  the  gums.  The  saliva  is  streaked  with  blood 
and  is  profuse ;  the  sub-maxillary  and  the  lymphatic 
glands  of  the  neck  are  generally  swollen.  There  will 
be  more  peevishness,  more  fever  and  more  salivation 
and  tenderness  than  in  the  simpler  inflammation,  and 
the  face  may  be  oedematous.  Mercury  causes  in 
adults  a  typical  picture  of  this  disease,  less  often  also 
had^  copper^  and  phosphorus. 

Ulcerative  stomatitis  is  distinguished  from  other 
diseases  of  the  mouth  by  the  appearance  of  the  gums 
before  uleration  begins,  by  the  irregularity  and  size 
of  the  ulcers,  which  in  the  folds  may  be  elongated 


154  PRESENT    STATUS    OF    PEDIATRICS. 

and  elsewhere  of  various  shapes,  and  by  the  accom- 
panying fetor  which  gives  it  its  popular  name.  Se- 
vere cases  of  stomacace  are  rare  in  private  practice, 
but  are  found  in  hospitals  where  occasionally  it  seems 
to  be  epidemic,  and  among  children  in  unhygienic 
surroundings  and  in  damp  seasons.  The  ordinary 
case  results  favorably  unless  the  patient  is  much  de- 
bilitated or  there  is  serious  co-existing  disease. 

Treatment. — All  food  and  drink  must  be  bland 
and  lukewarm.  The  treatment  will  be  materially 
aided  by  washes  of  the  permanganate  of  potasJi  (one 
grain  to  the  ounce)  or  Jiydrastis  (one-half  water). 
Mercuriiis  dulcis  is  the  chief  remedy  for  the  local  con- 
dition, although  arsenic^  Jiydrastis^  muriatic  acid,  etc. , 
may  be  necessary  for  more  general  conditions. 

APHTHOUS  STOMATITIS.— Still  another  form  of 
inflammation,  more  common  in  older  children  between 
the  first  and  second  dentition,  is  aphthous  stomatitis, 
aphthae,  or  "canker  sore  mouth."  Aphthae  is  a  fol- 
licular inflammation,  characterized  by  small,  round, 
superficial  ulcers,  most  frequently  seen  inside  the 
lower  lip,  of  clearly  defined  outline,  extremely  pain- 
ful to  touch,  and  of  grayish  appearance  when  mature. 
The  increase  of  mucus  and  saliva  in  this  affection  is 
never  sufficient  to  cause  the  offensive  odor  present  in 
most  inflammations  of  the  mouth.  Like  the  inflam- 
mation just  described,  aphthae  is  commonly  due  to 
errors  of  diet,  and  a  sequel  of  scarlatina,  measles,  and 
severe  gastric  and  intestinal  ailments ;  but  generally 
heals  in  from  three  to  twelve  days,  and  does  not  nec- 
essarily preclude  recovery  when  occurring  in  connec- 
tion with  severe  disease.     The   "plaques"  seen  on 


DISEASES    OF    THE    DIGESTIVE    TRACT.  1 55 

the  hard  palate,  close  to  the  velum,  one  on  either  side 
of  the  middle  line,  in  poorly  nourished  children,  are  a 
rare  form  of  aphthae,  and  if  persistent,  are  said  to  be 
a  prognostic  of  ill  omen  as  to  ultimate  recovery. 

Treatment. — Dental  authorities  state  that  the  ap- 
plication of  a  twenty  per  cent  solution  of  tri-cJiloride 
acetic  acid  upon  each  ulcer  is  specific  and  gives  very 
prompt  relief.  The  use  of  mucilaginous  washes,  and 
merctiriits  diilcis  or  arum  triphylluni  is  generally  ade- 
quate treatment. 

MEMBRANOUS  STOMATITIS  is  that  form  of  in- 
flammation in  which  a  so-called  false  membrane  is 
formed  in  or  on  the  mucous  membrane  of  the  mouth, 
said  membrane  leaving  an  ulcer  when  separated.  It 
occurs  mainly  in  diphtheria,  and  should  be  treated  as 
part  of  that  disease  {q.  v. ). 

THRUSH. — The  most  common  form  of  stomatitis 
in  early  infancy  is  a  disease  of  quite  different  nature 
from  those  thus  far  considered,  viz.  :  thrush,  white- 
mouth,  sprue,  or  stomatitis  mycosa,  an  affection  ac- 
companied by  only  slight  inflammation  of  the  mucous 
surface  and  characterized  by  the  growth  and  devel- 
opment of  a  specific  yeast  fungus  known  as  saccharo- 
viyces  mycodervia  (formerly  oidiiun  albicans).  The 
spores  of  this  vegetable  fungus  are  evidently  carried 
by  spoons,  bottles,  and  rubber  nipples — some  authori- 
ties claim  that  the  maternal  nipple  is  never  a  con- 
veyor of  this  growth  into  the  baby's  mouth,  and  are 
there  demonstrated  to  flourish  only  when  the  mucous 
surface  or  secretions  are  abnormal.  Because  acidity 
is  the  only  quality  yet  fairly  determined  to  be  neces- 
sary in  the  mouth  and  its  secretions  in  order  to  make 


156  PRESENT    STATUS    OF    PEDIATRICS. 

this  fungus  flourish,  it  is  assumed,  although  not  yet 
proven,  that  the  fungus  is  identical  with  that  which 
turns  milk  sour. 

Before  the  patches  of  fungus  appear,  spores  of  the 
fungus  may  be  found  in  the  secretions.  These 
patches  are  at  first  as  small  as  a  pin  head,  and  closely 
resemble  milk  curds,  being  pearly-white  in  color  and 
firmly  adherent,  but  as  they  spread  over  the  cavity 
and  become  older,  they  change  to  a  faint  yellow  color 
and  are  easily  detached.  The  whole  buccal  linings 
may  be  quickly  covered,  but  without  fetor  or  increased 
salivation ;  rather  is  the  mouth  dry  and  hot.  No  ul- 
cerated surface  appears  upon  the  removal  of  the 
growths  (except  in  severe  marasmus),  but  rather  a 
smooth,  shining  appearance  from  loss  of  the  epithe- 
lial cells. 

The  fungi  may  spread  further  down  the  alimentary 
canal,  especially  in  entero- colitis,  which  disease  thrush 
is  prone  to  complicate,  but  the  meagre  testimony  to 
its  having  "gone  through  the  child"  and  even  ap- 
peared at  the  anus  is  probably  apocryphal. 

Treatment. — Thrush  is  not  in  itself'  a  serious 
malady,  but  it  is  often  an  index  of  low  vitality,  and 
therefore  of  value  in  the  prognosis  of  exhausting 
gastro-enteric  diseases.  Cleanliness  of  the  mouth, 
that  is,  washing  all  parts  after  each  meal,  is  the  es- 
sential treatment.  This  may  be  accomplished  by 
painting  the  mouth  with  a  camel's  hair  brush  wet  in 
a  solution  oi  glycerine  and  borax  (about  16  to  2  parts), 
or  some  dilute  alkaline  fluid  as  vie/iy  or  Ihne  zvafer, 
or  spraying  with  a  dilution  of  one  drachm  of  borax  or 
sulpJiide  of  soda  to  an  ounce  of  water  to  which  a  little 


DISEASES    OF    THE    DIGESTIVE    TRACT.  157 

glycerine  has  been  added.  This  local  treatment  should 
be  supplemented  by  the  careful  selection  of  the  con- 
stitutional remedy  necessary  to  correct  the  mal-as- 
similation  or  gastro-enteric  symptoms  present.  Prob- 
ably c  ale  area  earbonica  most  often  covers  this  ground. 

CANCRUM  ORIS,  gangrene  of  the  mouth,  or  noma, 
is  a  secondary  disease  sometimes  consequent  upon 
measles,  small-pox,  scarlet  fever,  severe  ulcerative 
stomatitis,  etc.,  consisting  of  a  rapidly  destructive 
necrosis  of  the  cheek,  gums,  and  denser  tissues. 
This  disease  is  very  fatal,  but  fortunately  also  very 
rare  in  this  country.  Space  forbids  anything  more 
detailed  than  this  warning  statement  that  this  direful 
disease  begins  with  all  the  visible  signs  of  simple 
stomatitis,  and  that  the  thickening  and  dark-red  hue 
of  its  initial  point,  together  with  its  rapid  progress, 
are  attended  with  less  pain  than  in  other  forms  of 
stomatitis.  Of  course  prostration,  emaciation,  and 
the  conditions  that  accompany  gangrene  of  any  part 
soon  make  a  mistake  in  diagnosis  impossible. 

The  lesser  and  rarer  affections  of  the  mouth,  such 
as  gumboil,  glossitis,  ranula,  etc. ,  need  be  mentioned 
only  by  name.  Of  ranula,  however,  it  is  noteworthy 
that  recent  research  shows  it  to  be  a  mucoid  degen- 
eration of  some  of  the  lobules  of  the  Blandin-Nuhn 
gland,  situated  in  the  floor  of  the  mouth  and  imme- 
diately under  the  tongue,  and  not  an  accumulation  of 
saliva  from  Wharton's  duct,  as  formerly  thought. 

DE-NTITION.— The  teeth  are  so  much  in  evidence 
in  growing  children  that  a  word  concerning  dentition 
seems  necessary.  It  goes  without  saying  that  the 
teeth  are  in  the  gums  before  the  child  is  bom,  and 


158  PRESENT    STATUS    OF    PEDIATRICS. 

that  the  process  of  pushing  them  through  the  gums 
sometime  between  the  sixth  month  and  the  latter  half 
of  the  third  year  of  life  is  a  physiological  one,  and 
seldom  in  itself  a  cause  of  disease.  However,  in  this 
"nervous  age,"  the  normal  course,  at  least  in  the 
middle  and  higher  walks  of  life,  is  the  exception,  and 
rather  the  high  functional  activity  and  rapid  general 
tissue  changes  of  this  period  of  life  often  combine  to 
make  the  evolution  of  the  teeth  a  critical  process. 
Restlessness,  in  delicate  infants  a  temporarily  high 
temperature,  and  an  irritability  of  the  stomach  even 
with  vomiting,  diarrhoea,  or  convulsions,  are  some  of 
the  not  infrequent  evidences  of  irritation  during  the 
eruption  of  the  temporary  or  milk  teeth.  But  the 
gums  are  not  to  be  first  attacked  as  the  primary  cause 
of  the  disturbance.  Donkin  would  treat  the  above 
and  other  gastro-intestinal  symptoms  supposed  to 
arise  from  the  teeth  upon  their  own  merits,  and  never 
give  medicine  upon  '^  teething"  symptoms  alone. 
He  is  undoubtedly  right  in  believing  that  when  a 
child  so  suffers,  something  is  wrong  with  his  nourish- 
ment, and  therefore  would  carefully  scrutinize  his 
diet  and  general  hygiene.  Yet  it  seems  the  other  ex- 
treme to  say  with  the  same  writer  that  no  benefit, 
local  or  remote,  ever  comes  from  lancing  the  gums. 
The  writer  believes  that  there  must  be  a  middle 
ground  of  common  sense  between  the  recent  high 
authorities  on  children's  diseases  who  quite  condemn 
lancing,  and  the  dental  surgeons  who  always  unquali- 
fiedly favor  it.  He  has  certainly  occasionally  seen 
the  thorough  cross-scarification  of  hot  and  swollen 
gums,  and  the  consequent  relief  of  pressure  not  only 


DISEASES    OF    THE    DIGESTIVE    TRACT.  759 

Upwards  but  downwards,  and  the  complete  freeing  of 
the  tooth,  cause  prompt  cessation  of  serious  reflex 
symptoms.  All  writers  and  teachers  agree  that  symp- 
toms occurring  during  this  period  of  dentition  should 
be  promptly  met  by  remedies,  especially  ''colds"  as- 
sociated with  loose  lienteric  stools,  gastric  ailments, 
or  nervous  manifestations.  In  our  therapeutics  the 
all  pow^erful  remedy  for  any  and  all  of  these  com- 
plaints will  be  found  to  be  calcarea  carbonica. 

Children  should  be  early  taught  to  keep  their  teeth 
and  gums  clean.  Such  care  pays,  in  later  life,  large 
interest  on  the  necessary  patience  and  persistence 
originally  invested.  One  writer  thinks  that  mothers 
should  have  taught  their  children  by  the  end  of  the 
•second  year  to  keep  their  teeth  clean.  Be  this  as  it 
may,  the  mother's  duty  of  cleanliness  certainly  begins 
Avith  the  very  first  teeth.  When  from  neglect  or  bad 
inheritance  the  first  teeth  decay  early,  it  is  bad  prac- 
tice to  remove  them,  since  they  are  needed  to  pre- 
serve the  contour  of  the  jaw  for  the  proper  eruption 
of  the  permanent  teeth.  The  hornoeopathic  physician 
will  first  seek  to  arrest  this  decay  by  such  remedies 
as  krcosote^  stapJiysagria^  inercnriiis^  fluoric  acid^  etc. 
The  application  of  a  strong  solution  of  nitrate  of  sil- 
ver will  generally  check  superficial  caries.  If  these 
do  not  succeed,  such  teeth  should  be  by  all  means 
preserved  by  the  dentist's  art,  for  two  reasons,  viz. , 
first,  the  one  mentioned  above  as  the  objection  to 
their  early  removal,  and  second,  the  severe  indiges- 
tion which  will  surely  follow  the  child's  bolting  its 
food  because  of  its  sore  teeth. 

The  eruption  of  the  permanent  teeth  takes  about 


l6o  PRESENT    STATUS    OF    PEDIATRICS. 

as  many  years  as  that  of  the  temporary  does  months, 
and  is  therefore  usually  quite  free  from  any  compli- 
cations. 

II.— STOMACH. 

DYSPEPSIA. — In  infants  and  children  functional 
disturbances  of  this  organ  are  far  more  frequent  than 
actual  pathological  lesions,  and  therefore  the  general 
term  dyspepsia  first  deserves  attention.  Defects  in 
feeding,  errors  in  hygiene,  constitutional  disorders, 
and  certain  inheritance  commonly  cause  attacks  that 
do  not  reach  the  intensity  of  actual  inflammation  of 
the  stomach,  and  cause  no  lesion,  but  are  evidence  of 
lowered  nervous  force  and  require  as  careful  atten- 
tion from  the  practitioner  as  affections  with  a  more 
specific  or  higher-sounding  name.  Most  text-books 
describe  the  following  conditions  under  acute  gastric 
catarrh,  but  they  will  be  found  to  be  purely  functional. 

Symptoms. — Brought  about  by  any  of  the  above 
noted  general  causes;  they  are  evidenced  in  infants 
by  pallor,  weakness  moaning  cries,  hot  dry  skin,  rest- 
less broken  sleep,  the  whole  train  of  symptoms  being 
perhaps  relieved  in  a  few  hours  by  profuse  vomiting 
of  curdled  milk,  or  there  may  be  a  slight  elevation 
of  temperature,  tender  epigastrium,  and  constipation, 
relief  coming  physiologically  by  a  brief  diarrhoea  of 
undigested  food.  If  nausea  and  vomiting  be  the 
most  striking  symptom,  it  is  best  to  give  nothing  but 
pure  water  and  allow  Nature  to  effect  relief  by  full 
emesis,  always  remembering  that  such  vomiting  may 
usher  in  many  serious  forms  of  infantile  diseases. 
The  writer  believes  that  very  young  children,  even 
infants,  commonly  from  too  much  or  improper  feed- 


DISEASES    OF    THE    DIGESTIVE    TRACT.  l6l 

ing,  have  attacks  similar  to  those  called  ''bilious" 
or  "sick-headache"  in  adults,  and  that  their  entire 
abstinence  from  food  and  perfect  quiet  is  the  proper 
treatment.  Children  of  nervous,  rheumatic,  or  tuber- 
cular inheritance  are  more  liable  to  such  attacks  than 
others  and  with  them  convulsions  often  complicate. 
Not  infrequently  is  this  tendency  to  dyspepsia  ap- 
parently a  direct  inheritance  from  one  or  both  pa- 
rents, and  then  a  source  of  constant  solicitude  until 
the  close  of  dentition. 

In  older  children,  flatulence,  attacks  of  abdominal 
pain  or  severe  colic,  a  peevish  whining  disposition, 
night-mare  and  a  more  or  less  constantly  coated 
tongue  and  foul  breath,  are  indices  of  this  condition. 
With  them  and  with  younger  children  the  cautious 
physician  will  have  in  mind  when  called  to  these 
"stomach  spells"  the  possible  onset  of  severe  acute 
disease  and  carefully  examine  the  throat,  chest,  and 
the  urine  at  his  first  visit. 

Chronic  Dyspepsia. — When  these  conditions  of 
dyspepsia  become  chronic  they  are  still  of  paramount 
interest  to  the  practitioner,  since  they  try  his  patience 
and  ability  to  the  utmost.  The  books  describe  what  is 
here  meant  under  various  headings,  e.  g. ,  marasmus, 
inanition,  wasting,  athrepsia  (MM.  Parrrot  and  Robin), 
and  congenital  dyspepsia  (Tooker).  These  terms  all 
refer  alike  to  functional  impairment  of  the  digestive 
apparatus,  without  any  ascertainable  lesion,  and  are 
easily  distinguishable  from  the  acute  and  certain 
chronic  gastro-intestinal  disorders  by  lack  of  con- 
tinued fever. 

Treatment. — In  the  treatment  of  these  cases  the 


l62  PRESENT    STATUS    OF    PEDIATRICS. 

simpler  the  methods  the  more  successful  the  results. 
Minute  attention  to  every  detail  of  the  child's  life, 
/.  e. ,  dress,  bathing,  ventilation,  rest,  exercise,  as  well 
as  diet,  are  absolutely  essential  to  the  cure  of  these 
tendencies.  Calcarea  carbofiica  in  infants,  and  7iux 
podopJiyllin^  and  sulpJuir  in  older  children,  are  perhaps 
the  most  commonly  indicated  remedies. 

ACUTE  GASTRITIS.— If  it  be  remembered  that 
true  gastritis  is  an  inflammation  of  the  stomach  in- 
volving all  its  coats  and  is  therefore  of  rare  occurrence 
in  children,  being  then  due  to  external  injury  or  in- 
ternal and  extraordinary  irritation,  the  term,  as  usu- 
ally applied  to  an  acute  catarrhal  inflammation  of  the 
mucous  membrane  of  the  stomach,  gastric  catarrh, 
will  be  clearly  understood.  Such  attacks  are  amaz- 
ingly common  in  children,  from  defective  feeding, 
insufflcient  clothing,  bad  sanitation,  dentition,  or 
from  all  combined  to  reduce  the  resistance  of  the 
child ;  or  less  often,  from  too  hot  or  too  cold  liquids 
or  irritant  emetic  drugs.  The  symptoms  are  those 
described  under  dyspepsia  in  an  aggravated  form. 
Vomiting  is  more  constant  and  may  extend  to  retch- 
ing of  a  little  bile-stained  mucus  or  even  blood ;  the 
tongue  is  heavily  coated,  often  with  raised,  reddened 
papillae,  as  in  the  beginning  of  scarlet  fever,  for 
which  these  attacks  are  sometimes  mistaken ;  breath 
sour  and  disagreeable,  epigastric  tenderness,  temper- 
ature to  I02  degrees  and  above,  and  constipation; 
nervous  symptoms  are  not  uncommon,  even  to  con- 
vulsions in  infants. 

Treatment. — The  first  essential  of  treatment  is 
absolute  rest  of  the  afflicted  organ,  best  accomplished 


DISEASES    OF    THE    DIGESTIVE    TRACT.  163 

by  putting  the  patient  to  bed  and  giving  nothing  but 
water  or  cracked  ice,  the  latter  especially  if  there  be 
much  vomiting.  If,  after  twenty-four  hours  or  more 
of  such  rest,  neither  barley  or  rice  water,  milk  and 
water,  or  mutton  broth  can  be  borne,  nutrient  enemata 
should  be  given  and  kept  up  until  the  inflammation  has 
subsided;  then  such  foods  as  predigested  milk  and 
light  broths  until  the  tongue  clears  and  the  appetite  as- 
serts itself.  Bryonia^  calcarea  carbonica,  arsenic,  and 
argentum  nitricum  are  perhaps  most  often  indicated. 
Repeated  attacks  of  this  kind  should  warn  the  prac- 
tioner  of  a  possible  neurosis,  such  as  la  petit  inal. 

CHRONIC  GASTRITIS.— Chronic  gastritis  is  most 
often  seen  among  children  of  the  poorer  classes,  from 
overcrowding  and  unhygienic  living,  especially  the 
allowing  of  table  food  too  early. 

Symptomatolog'y. — They  suffer  from  irregular 
vomiting,  oftentimes  of  fragments  of  food  and  an 
acid  fluid,  fetid  eructations,  red  dry  lips,  and  a  con- 
stantly coated  tongue,  constipation  with  much  strain- 
ing and  hard  scybalous  stools.  The  child  begins  to 
emaciate  and  its  features  grow  pinched.  This  may  go 
for  months,  when  finally  all  food  is  rejected  by  more 
frequent  vomiting,  the  temperature  drops  below  nor- 
mal, the  secretions  and  excretions  become  sour  and 
fetid,  and  the  patient  sinks  into  stupor  and  dies  from 
exhaustion.  This  condition  need  not  be  confused 
with  chronic  dyspepsia,  at  least  until  emaciation  is 
quite  marked,  for  there  is  always  some  fever  in 
chronic  gastritis. 

Treatment. — In  prescribing  for  this  form  of  gas- 
tritis, any  remedy,  selected  with  the  greatest  skill 


164  PRESENT    STATUS    OF    PEDIATRICS. 

from  the  whole  materia  medica,  may  be  the  curative 
one,  and  moreover  the  patient  will  often  thrive  in 
convalescence  upon  what  a  properly  acting  stomach 
would  scorn.  Especially  essential  to  recovery  is 
warmth  of  the  body  and  abundant  fresh  air  and  sun- 
shine. These  are  the  cases  also  in  which  lavage  is 
sometimes  employed  to  great  advantage. 

Such  rare  diseases  of  the  stomach  in  children  as 
stenosis,  dilatation,  ulcer,  and  hemorrhage  are  best 
studied  in  Keating  or  works  on  general  practice,  bear- 
ing in  mind  the  fact  that  such  conditions  are  more 
dangerous  and  more  apt  to  be  quickly  fatal  in  chil- 
dren than  in  adults. 

Vomiting",  while  merely  a  gastric  symptom,  de- 
serves a  moment's  special  consideration.  In  infants, 
owing  to  the  more  vertical  position  of  the  stomach,  it 
is  a  physiological  act  and  a  relief  to  an  overloaded 
stomach,  but  is  often  converted  into  a  pernicious 
habit  by  either  laying  the  baby  down  or  bringing  it 
into  an  upright  position  too  soon  after  its  meal.  In- 
digestion commonly  accounts  for  it  in  older  children, 
although  many  acute  diseases  of  childhood  begin  with 
sudden  and  violent  vomiting.  Vomiting  at  any  age 
of  childhood  may  also  be  reflex  from  tumor  or  inflam- 
mation of  the  brain,  pertussis,  chronic  lung  disease, 
dentition,  or  worms.  That  from  brain  disease  is  most 
serious,  and  is  recognized  by  its  suddenness  and 
irregular  appearance,  the  absence  of  gastro-intestinal 
symptoms,  a  clean  tongue,  and  such  cerebral  symp- 
toms as  headache,  weak  vision,  general  muscular 
twitching,  and  probably  an  intermittent  pulse. 


DISEASES    OF    THE    DIGESTIVE    TRACT.  l6$ 

III.— LIVER. 

ICTERUS  (Jaundice).— The  radical  changes  in  the 
circulation  consequent  upon  birth  account  for  the 
yellowness  of  the  skin  which  commonly  follows  the 
first  congestion  of  that  covering  (as  after  bruises  in 
later  life),  but  this  does  not  constitute  true  icterus, 
imless  the  conjunctiva  and  urine  are  discolored. 
"Icterus  neanatorum,"  or  the  mildest  form  of  jaun- 
dice, appears  most  commonly  in  those  born  prema- 
turely or  asphyxiated,  or  those  enfeebled  by  prolonged 
labor  or  any  other  cause,  and  is  therefore  most  often 
seen  in  foundlings  (seventy  per  cent).  Appearing  upon 
the  second  or  third  day  of  life,  it  causes  no  greater 
disturbance  than  a  loss  of  weight  and  perhaps  a 
slower  gain  for  a  time  thereafter,  and  generally  dis- 
appears in  a  few  days  with  systematic  and  careful 
feeding,  and  possibly  occasional  doses  of  chelidoniuin 
ox  podopJiyllin. 

Grave  forms  of  icterus  in  infants  may  appear  later 
than  the  third  day  with  discolored  conjunctiva  and 
urine,  enlargement  of  the  abdomen,  progressive  wast- 
ing, and  generally  death.  Malformation  of  the  bile 
ducts,  congenital  syphilis,  and  more  rarely  and  most 
fatally,  septic  poisoning  from  umbilical  phlebitis,  with 
oozing  of  pus  and  blood  and  an  elevated  temperature 
in  the  latter  instance,  account  for  those  cases. 

In  older  children  jaundice  is  usually  the  most  troub- 
lesome symptom  of  some  occlusion  of  the  bile  ducts, 
either  from  a  plug  of  inspissated  bile,  gall-stones 
(rarely),  a  round  worm  (occasionally),  catarrhal  in- 
flammation of  the  'duodenum  or  inflammation  of  the 
liver  itself,  due  to  malarial  or  drug  poisoning.     Duo- 


l66  PRESENT    STATUS   OF    PEDIATRICS. 

denitis  or  gastric-duodenitis  is  present  when  nausea 
and  vomiting,  with  tenderness  in  or  just  below  the 
epigastrium  and  pain  some  hours  after  taking  food, 
accompany  the  icterus.  The  stools  in  this  form  will 
be  the  natural  brownish-yellow,  unless  the  obstruction 
is  complete,  when,  even  without  the  above  inflamma- 
tory conditions  or  any  especial  change  in  nutrition, 
the  stools  contain  undigested  fat  and  are  clay-colored 
from  total  absence  of  bile.  Constipation,  a  slower 
pulse,  and  mental  hebetude,  from  the  sedative  effects 
of  the  biliary  salts  upon  the  circulation,  complete  the 
picture  which  may  last  days  or  even  weeks. 

Treatment. — The  inflammatory  symptoms  should 
be  treated  upon  the  indications,  probably  with  such 
specific  drugs  as  podopJiyllin,  Jiydrastis^  cJielidonium^ 
mercitrius  dulcis^  phosphorus^  and  kali  bicJiromicum. 
If  purgatives  seem  necessary  at  first,  never  use  irri- 
tating drugs,  but  rather  such  mineral  waters  as  Carls- 
bad, Vichy,  and  Congress.  Only  easily  digested, 
mainly  liquid,  foods  without  fats  are  allowable,  with 
free  use  of  lemon  or  lime  juice  in  chronic  cases. 
The  catarrhal  tendency  underlying  the  latter  cases 
must  be  reached  by  a  remedy  that  covers  more  than 
the  local  symptoms.  Daily  warm  baths  are  of  great 
benefit. 

There  is  not  space  for  anything  more  than  mention 
of  the  rare  forms  of  liver  affections  in  childhood,  such 
as  fatty  or  amyloid  infiltration,  hydatids,  abscess,  tu- 
mors, etc. ,  evidenced  by  enlargement  of  this  organ, 
or  the  still  rarer  diseases  accompanied  by  contractions, 
as  cirrhosis,  and  acute  yellow  atrophy.  (See  Keating, 
vol.  Ill,  pp.  422-515.) 


DISEASES    OF    THE    DIGESTIVE    TRACT.  1 67 

In  growing  children  nurtured  in  ' '  the  hot  bed  of 
modern  civilization"  the  livers  often  become  like 
those  of  the  Strasburg  geese,  congested  and  enlarged 
as  the  result  of  overfeeding,  overheating,  want  of  ex- 
ercise and  fresh  air,  and  causing  frequent  indigestion, 
languor,  and  irritability,  even  without  actual  jaun- 
dice. Common  sense  indicates  the  proper  treatment 
of  such  cases.  Still  another  class  of  children  will  be 
found  to  be  suffering  from  a  functional  disturbance  of 
the  liver  and  a  variety  of  nervous  and  dyspeptic 
symptoms,  such  as  constipation,  headaches,  and  ca- 
pricious appetites.  Attention  to  the  urine  of  such 
patients  will  show  frequent  passages  and  probably  a 
pinkish  sediment,  and  a  general  dietetic,  hygienic, 
and  medical  treatment  for  lithaemia  as  found  in  adults 
will  effect  a  cure,  lycopodinin^  natruni  sidpJiuricuni^ 
and  litJiitun  carbonicum  being  the  chief  homoeopathic 
remedies  therefor. 

IV.— ABDOMEN. 

A.  — DIARRHCEA.  — This  rather  general  term, 
meaning  simply  "  to  blow  through,"  and  implying  a 
functional  disturbance  of  the  alvine  evacuations,  re- 
sulting in  their  unusual  frequency  and  more  or  less 
changed  consistency,  has  come  to  be  used  for  a  variety 
of  pathological  states.  It  is  employed  here  as  only  a 
convenient  heading  for  all  conditions  (except  cholera 
infantum,  q.  v.)  as  distinguished  from  the  opposite 
state  of  constipation. 

It  is  not  possible  clinically  to  classify  intestinal  af- 
fections as  simply  as  those  of  the  stomach,  viz.,  func- 
tional,  acute,   or   chronic   catarrh,    ulceration,    etc., 


l68  PRESENT    STATUS   OF    PEDIATRICS. 

since  new  elements  enter  into  this  part  of  the  alimen- 
tary canal  in  the  shape  of  bacteria,  and  the  pathology 
is  confused  by  the  length  of  the  canal  and  the  varie- 
ties of  structures  and  functions  involved.  It  often 
happens  that  catarrhal  inflammation  of  the  stomach 
extends  on  into  the  intestines,  but,  as  Donkin  says,  it 
is  always  well  in  considering  intestinal  troubles  ii 
which  diarrhoea  is  a  prominent  symptom  to  leave 
"catarrh"  out  of  the  conception  and  think  of  the 
functions  of  digestion  and  absorption. 

The  normal  stool  of  infancy  is  soft,  papescent,  of 
light-yellow  color,  devoid  of  fetor  and  of  homogene- 
ous character,  taking  on  deeper  color  and  more  con- 
sistency as  life  advances.  The  variations  from  this 
standard  are  legion,  and  of  differing  clinical  signifi- 
cance. The  presence  of  mucus  in  a  stool  may  mean 
simply  irritation  from  worms  or  teething,  but  more 
commonly,  especially  when  viscid  or  bloody,  some  in- 
flammatory affection.  Bright  blood  commonly  comes 
from  the  colon,  that  from  the  upper  intestine  being 
generally  browm.  Bloody  stools  in  children  are  not 
necessarily  or  usually  the  result  of  ulceration,  but 
rather  of  intense  intestinal  congestion.  Lienteric 
stools  signify  an  extreme  irritability  of  the  alimentary 
canal,  which  may  precede,  accompany,  or  follow  in- 
flammation, being  seldom,  as  in  adults,  a  purely  nerv- 
ous phenomenon. 

Diarrhoea  is  one  of  the  commonest  symptoms  of 
infancy,  and  is  often  a  salutary  effort  of  Nature  re- 
quiring no  treatment  but  to  be  let  alone.  However, 
when  serious  enough  to  involve  pathological  changes, 
it  has  received  various  classifications.     Some  divide 


DISEASES    OF    THE    DIGESTIVE    TRACT.  l6g 

the  various  diarrhoeal  diseases  according  to  their  ana- 
tomical location,  which  would  be  ideal  if  practically 
it  did  not  usually  require  a  post-mortem  examination 
to  confirm  or  disprove  the  diagnosis ;  others,  from  the 
nature  of  the  discharges,  into  mucous,  bilious,  or  se- 
rous, which  would  be  decidedly  practical  if  one  and 
the  same  attack  did  not  often  involve  all  three  varie- 
ties of  stools.  The  generally  adopted  plan  is  the  fol- 
lowing, given  in  brief : 

I.  NON-INFLAMMATORY  DIARRHCEA.— Simple 
infantile,  or  non-inflammatory  diarrhoea  (muco-enteri- 
tis,  catarrhal  enteritis),  is  characterized  by  thin  watery 
stools,  without  tenesmus  or  appreciable  elevation  of 
temperature,  and  unattended  by  any  tissue  change 
other  than  tumefaction  of  the  intestinal  follicles  and 
diminished  firmness  of  the  mucous  membrane.  Mod- 
ern authors  are  gradually  discarding  the  older  classifi- 
cation of  Niemeyer,  of  all  diarrhoeas  as  catarrhal, 
and  indeed  rarely  attribute  any  marked  diarrhoea  to 
cold  alone. 

Causes. — Anything  in  the  alimentary  canal  not 
assimilable,  anything  capable  of  checking  the  skin 
functions  and  thus  congesting  the  mucous  membrane, 
and  anything  decidedly  disturbing  to  the  circulation, 
may  be  the  cause ;  therefore,  farinaceous  food  or  a 
mixed  diet  begun  too  early,  insufficient  clothing  in  a 
changeable  climate,  extreme  heat,  or  dentition,  or,  as 
most  often  happens,  a  combination  of  these,  are  a  few 
of  the  most  important  etiological  factors  ' '  whose 
name  is  legion." 

Symptomatology. — Symptoms  of  indigestion  may 
precede  the  attack  a  day  or  two,  or  the  onset  be  sud- 


170  PRESENT    STATUS    OF    PEDIATRICS. 

den,  even  with  nausea  and  vomiting,  although  the  lat- 
ter conditions  are  commonly  held  to  mean  an  inflam- 
matory attack.  The  tongue  is  moist  and  there  is  but 
little  thirst  unless  the  stools  are  very  frequent.  These 
stools  are  thin,  watery,  of  changed  (generally  green- 
ish) color,  not  fetid ;  they  may  contain  some  mucus, 
and  vary  from  three  or  four  to  twenty  or  more  in  each 
twenty-four  hours.  The  emaciation  accompanying 
this  form  is  often  amazing,  and  constitutes  with  its 
exhaustion  the  only  danger,  especially  in  very  young 
infants. 

Treatment. — The  use  of  belladonna^  cJianioniilla^ 
croton  tigliiini,  or  podophyllin,  is  generally  all  suffi- 
cient, and  vastly  superior  to  the  routine  treatment 
with  castor  oil  and  astringents.  Such  cases  are  not 
to  be  held  as  cured  until  the  stools  become  normal, 
even  the  loose  discharges  have  ceased. 

2.  ENTERO-COLITIS,  inflammatory  or  febrile  diar- 
rhoea, ''summer  diarrhoea,"  are  the  accepted  terms 
for  diarrhoeal  attacks  attended  with  fever  and  other 
symptoms  of  intestinal  inflammation,  and  include  the 
"dysenteric  diarrhoea"  and  the  dysentery  of  child- 
hood ;  and  may  be  either  acute  or  chronic. 

It  is  clinically  well  nigh  impossible  to  make  anato- 
mical distinctions  as  to  the  exact  location  of  the 
lesions  in  this  complaint,  but  this  much  is  of  value: 
Stools  from  the  small  intestine  are  accompanied  with 
colicky  pain  and  are  fecal,  yellow,  andflocculent,  while 
those  from  the  colon  or  below  are  more  mucous,  gray- 
ish, and  granular,  and  accompanied  by  more  straining. 
The  lesions  include  locally  acute  desquamative  ca- 
tarrh with  loss  of  epithelium,  acute  inflammation  of 


DISEASES    OF    THE    DIGESTIVE    TRACT.  171 

the  lymph  nodules  and  (follicular)  ulceration,  croupous 
inflammation,  with  colliquitive  injection  of  the  adja- 
cent peritoneum,  enlargement  of  the  mesenteric 
glands,  and  perhaps  catarrhal  inflammation  of  the 
mucous  membrane  of  the  stomach. 

Causes. — The  causation  of  entero-colitis  includes 
all  mentioned  under  the  last  caption  and  much  more. 
For  instance,  simple  residence  in  large  cities — and  es- 
pecially is  this  true  of  American  cities — as  contrasted 
with  the  country,  even  without  the  bad  hygiene  and 
overcrowding  that  enter  into  most  cases ;  such  consti- 
tutional inheritance  as  syphilis,  rickets,  and  tubercu- 
losis, and  the  advent  of  pneumonia,  measles,  whoop- 
ing-cough; bottle-fed  as  contrasted  with  nursing 
infants  (ninety-seven  to  three  per  cent  of  deaths) ; 
the  telluric  and  atmospheric  influences  of  June,  July, 
and  August,  the  disease  being  comparatively  rare  in 
winter,  etc.  The  fact  that  it  occurs  most  commonly 
from  the  sixth  to  the  eighteenth  month  should  make 
dentition  a  more  potent  factor  than  many  authors  ad- 
mit. 

Stools. — The  character  of  the  stools  vary  greatly 
in  entero-colitis.  They  may  be  at  first  only  thinner 
and  more  frequent,  as  in  simple  diarrhoea,  and  of  vary- 
ing color,  but  soon  take  on  a  very  offensive  odor,  and 
contain  mucus,  undigested  food,  especially  caseine, 
still  later  blood  and  pus.  In  protracted  cases  the 
acidity  of  the  frequent  stools  causes  an  excoriation  of 
the  nates  and  thighs.  The  tongue  changes  from  a 
condition  of  moisture  to  one  of  dryness  and  has  a 
more  decided  coating ;  the  lips  crack  and  bleed.  The 
continued  fever  is  accompanied  by  prostration,  and 


172  PRESENT    STATUS    OF    PEDIATRICS. 

the  more  serious  symptoms  gradually  creep  on.  Any 
variety  of  sore  mouth  may  be  present,  but  thrush  is 
most  common. 

Prog'nosis. — While  this  disease  is  always  serious,  it 
is  not  necessarily  fatal,  although  protracted  for  weeks. 
If  the  stools — which  should  always  be  carefully  in- 
spected in  all  infantile  complaints — show  by  their  con- 
stant green  color,  mucus,  and  occasional  blood  that 
follicular  inflammation  is  probable,  the  outlook  is  bad. 
There  is  constant  danger  of  infectious  diarrhoea,  or 
cholera  infantum,  and  of  brain  complication  because 
of  extreme  exhaustion.  Serous  effusion  into  the 
brain  is  impending  if  there  is  stupor,  restlessness 
and  a  return  of  the  vomiting. 

Treatment. — The  first  necessity  in  treatment  is  a 
change  of  environment,  even  those  from  sanitary 
homes  being  immediately  improved  by  removal  to 
the  country  or  sea-shore.  At  least  a  public  park  or 
square  can  be  found,  or  some  cool  spot  for  the  heat  of 
the  day.  The  child  should  not  be  handled  any  more 
than  is  absolutely  necessary,  and  be  put  into  a  cool, 
clean  bed  for  its  naps  and  at  night.  The  clothing 
should  be  clean  and  cool,  with  flannel  next  to  the 
bowels,  and  the  child  be  sponged  and  gently  dried 
each  day.  These  common-place  directions  are  em- 
phasized here  because  they  are  all-important  in  the 
management  of  this  disease.  The  intense  thirst  may 
be  allayed  with  cracked  ice,  and  water  freely  used, 
best  boiled  or  distilled. 

It  is  often  necessary  to  stop  milk  in  any  form  in  in- 
fants, and  substitute  barley,  rice,  or  toast  water,  and 
if  the  case  be  tedious,  delicately  made  mutton  broth. 


DISEASES    OF    THE    DIGESTIVE    TRACT.  1 73 

WliiLe  oi  eggs  in  water  often  supplies  the  necebsaiy 
albumen.  Koumiss  answers  in  some  cases,  as  do  oc- 
casionally one  of  the  patent  milk  foods.  If  milk  can 
be  used  it  should  always  be  sterilized  and  peptonized. 

Irrigation  of  the  bowels  can  do  no  harm  and  prob- 
ably has  good  mechanical  effect  to  cleanse  and  soothe 
and  probably  act  as  an  astringent  to  the  congested 
mucous  membrane.  Either  a  two  part  solution  of 
boric  acid^  or  a  ten  to  fifteen  per  cent  of  hamamelis 
when  the  stools  are  bloody,  can  be  given  to  the  amount 
of  a  gallon  through  a  large  flexible  catheter  or  rub- 
ber rectal  tube.  But  Demme,  Donkin,  and  others 
agree  that  such  mechanical  treatment  when  employed 
as  an  antiseptic  is  far  from  satisfactory.  Irrigation 
is  still  on  trial,  its  theoretical  promise  being  much 
greater  than  its  practical  performance.  Moist  and 
hot  applications  may  afford  at  least  temporary  relief 
and  comfort  to  the  little  patient,  although  they  are  of 
little  use  in  allaying  inflammation  unless  persisted  in 
with  religious  exactness. 

The  selection  of  the  remedy  for  entero-colitis  is  a 
very  delicate  task,  and  involves  a  close  study  of  the 
history,  constitution,  and  general  symptoms,  as  well 
as  the  character  of  the  stools.  Arsenic^  cethusa, 
podopJiyllin^  and  siilpJiiir  are  often  indicated,  while 
ipecacuanJia^  vicrciirius  soliibis  and  corrosiviis^  rhiis, 
and  iris  more  often  suit  the  dysenteric  forms. 

3.  DIARRHCEA  OF  BACTERIAL  ORIGIN.— Dr.  L. 
Emmett  Holt,  whose  article  (Keating,  vol.  Ill)  on 
the  diarrhoeal  diseases  is  probably  one  of  the  best  in 
our  language,  makes  another  class  called  acute  my- 
cotic diarrhoeas,  or  those  of  bacteriological  origin,  and 


174  PRESENT    STATUS    OF    PEDIATRICS. 

therefore  infectious,  in  which  class  he  would  place 
those  treated  as  "summer  complaint"  (applicable  to 
many  acute  gastro-intestinal  catarrhs)  and  cholera  in- 
fantum {q.  v.).  His  views  are  quite  generally  ac- 
cepted. Researches  in  the  intestinal  bacteriology  of 
children  (see  Dr.  Booker's  article  in  same  volume  of 
Keating)  have  disclosed  two  constant  and  normal  bac- 
teria in  the  intestine,  viz. ,  bacterium  lactis  serogenes 
and  bacterium  coli  commune,  and  also  in  the  dejecta 
of  infants  suffering  from  summer  diarrhoea  some 
forty  more  or  less  constant  varieties.  The  relation 
of  these  two  classes  as  preventative  or  causative  of 
disease  is  not  yet  by  any  means  determined.  The 
first  class,  the  two  normal  bacteria  of  the  intestinal 
canal,  seem  innocuous  and  possibly  also  act  as  scav- 
engers upon  the  forty  foreign  or  possibly  pathogenic 
bacteria.  Experiments  do  not  consistently  show  that 
the  latter  possess  as  a  class  pathogenic  properties, 
and  conclusions  thus  far  apparently  demonstrate  that 
many  kinds  of  different  bacteria  manifest  their  action 
by  altering  the  food  and  the  intestinal  contents  and 
thus  producing  injurious  products,  rather  than  by  the 
direct  irritation  of  the  mucous  membrane.  Until  the 
bacteriologists  reach  more  definite  results  the  practi- 
cal deductions  are  ( i)  that  micro-organisms  play  a  far 
more  important  part  on  food  contamination  in  infancy 
than  in  adult  life;  (2)  that  careful  sterilization  and 
preparation  of  infant  food  is  a  necessity;  and  (3)  that 
local  and  antiseptic  treatment  of  diarrhoeal  diseases, 
while  ideal  from  this  standpoint,  is  not  yet  of  estab- 
lished practical  value. 

B.— CONSTIPATION.— This  is  a  relative  term  ap- 


DISEASES    OF    THE    DIGESTIVE    TRACT.  1 75 

plied  to  inactivity  of  the  bowels,  whereby  the  usual 
evacuation  of  fecal  matter  is  postponed  from  twenty- 
four  hours  in  the  infant  to  a  much  longer  period  in 
later  life.  The  most  frequent  cause  of  constipation 
in  infancy  is  lack  of  fluid,  not  the  fluid  in  the  food, 
which  is  in  large  proportion,  but  water,  which  the 
baby  often  needs  instead  of  food,  and  was  evidently 
intended  by  Nature  to  be  freely  used  at  all  ages. 
Other  causes  are  feeble  expulsive  powers,  a  dried  con- 
dition of  the  fecal  mass  from  too  little  mucous  secre- 
tion of  the  intestinal  mucous  membrane,  too  much 
starch  or  caseine  in  the  food,  fissure,  and  other  ailments 
at  the  anus ;  the  continued  use  of  purgatives,  which 
will  fix  the  constipated  habit  at  any  age ;  the  mother's 
constipation  reflected  in  the  nursing  infant;  and, 
finally,  the  slowing  up  of  the  whole  machinery  of 
alimentation  in  all  cerebro-spinal  diseases.  In  older 
children,  more  in  girls  than  boys,  indigestion,  im- 
proper food,  diseases  of  the  stomach  and  liver,  syphi- 
lis, malaria,  etc. ,  are  common  causes. 

Symptomatolog'y. — In  infants  this  condition  is 
frequently  accompanied  with  colic,  pallor,  flushed 
face,  hot  head,  and  temporarily  high  temperature; 
while  in  older  children,  furred  tongue,  offensive 
breath,  headache,  colic,  bad  sleep,  and  moroseness  are 
its  concomitants. 

Treatment. — It  is  well  to  always  make  a  physi- 
cal examination  of  all  cases  reported  as  constipation 
or  diarrhoea  before  instituting  treatment,  and  is  gen- 
erally wise,  in  the  former  instance,  to  thoroughly  ex- 
amine the  rectum.  Acute  constipation  never  requires 
a  purgative,  but  may  be  wisely  and  safely  neglected 


176  PRESENT    STATUS    OF    PEDIATRICS. 

for  a  while  (Donkin),  an  enema  of  hot  soap  suds  or 
glycerine  and  water  (one-half  each),  or  glycerine  or 
wheat  gluten  suppositories,  or  even  the  time-honored 
cone  of  soap,  being  indicated  if  Nature  does  not  act 
within  a  few  days.  Regularity  in  the  action  of  the 
bowels  should  be  inculcated  very  early  in  life,  for 
much  constipation  at  any  age  is  due  to  downright 
carelessness.  In  bottle-babies,  well  cooked  and 
strained  oatmeal  gruel  may  be  substituted  for  the 
water  in  diluting  the  milk,  with  excellent  results ;  or 
massage  of  the  abdomen  carefully  resorted  to.  An 
exclusive  diet  of  cow's  milk  almost  always  results  in 
constipation,  and  must  be  cured  by  substitution  of 
some  aid  to  the  digestion  of  the  caseine.  Then  the 
use  of  some  dextrinized  and  malted  food,  as  Mcllin's 
Food^  is  indicated,  or  a  teaspoonful  of  a  good  malt  ex- 
tract to  the  bottle  of  milk.  In  older  children  the  ad- 
dition of  baked  apples  or  stewed  fruit  to  their  dietary, 
and  a  careful  regulation  of  the  same  generally  cures. 
Merely  purgative  drugs  are  condemned,  certainly  by 
all  homoeopathic  authorities  and  by  the  best  of  all 
schools,  as  but  temporary  stimulants  to  be  used  only 
in  smallest  doses,  and  as  seldom  as  possible.  Niix^ 
sulplnir^  bryonia^  altiniina,  nitric  acid^  etc.,  make  such 
expedients  as  the  latter  unnecessary  to  the  homoeo- 
pathist. 

INTESTINAL  PARASITES.— The  animal  parasites 
which  disturb  childhood  are  of  but  few  varieties  and, 
contrary  to  popular  belief,  comparatively  rare.  They 
commonly  enter  the  child's  system  as  an  embryo  or 
^ZZ  derived  from  the  domestic  animals,  either  through 
uncooked  flesh,  from  raw  fruits  and  vegetables  that 


DISEASES    OF    THE    DIGESTIVE    TRACT.  1 77 

have  been  fertilized  by  liquid  manure,  unfiltered 
water,  or  self-infection  from  uncleanliness.  There 
must  be,  as  the  older  writers  believed,  a  basis  or  soil 
upon  which  these  parasites  flourish,  since  they  attack 
comparatively  few  of  the  hundreds  exposed  to  the 
above  causes.  As  confirming  the  idea  that  something 
in  the  condition  of  the  alimentary  canal  favors  these 
visitors,  as  an  acid  condition  of  the  mouth  does  thrush, 
a  recent  English  authority  is  quoted  (Arch,  of  Ped,, 
1895,  p.  243)  as  advocating,  not  anthelmintics,  but  an 
exact  application  of  a  proper  diet  as  the  best  preven- 
tion. Probably  a  proper  state  of  resistance,  i.  e., 
thorough  nourishment  or  good  health,  is  incompatible 
with  the  existence  of  parasites.  In  the  order  of  their 
clinical  frequency  the  following  are  the  varieties  that 
most  often  affect  children : 

I.  Oxyuris  vermiculosis,  the  seat,  thread,  or  pin- 
worm,  is  the  most  minute  and  common  parasite  es- 
pecially of  infancy  and  early  childhood.  It  is  whitish 
or  semi-transparent,  varies  in  length  from  one  to  five 
lines,  and  is  thought  to  have  its  home  in  the  rectum 
and  sigmoid  flexure.  These  worms  propagate  with 
great  rapidity,  and  cause  by  their  migrations  about 
the  anus  and  genitals  the  most  intolerable  itching, 
and  sometimes  a  mucous  or  even  bloody  diarrhoea, 
and  prolapsis  ani.  Frequent  micturition,  excitement 
of  the  genitals  in  older  children,  and  leucorrhoea  may 
also  arise  from  these  worms,  and,  according  to  some 
authors,  convulsions. 

Diag'nosis. — The  readiest  means  of  diagnosing  the 
presence  of  these  worms  is  by  inspection  of  the  anus 
under  a  bright  light  shortly  after  the  child  has  gone 

13 


lyS  PRESENT    STATUS    OF    PEDIATRICS. 

to  bed  for  the  night,  but  it  must  be  done  very  quickly, 
else  these  wanderers  will  have  sought  their  warm 
quarters  and  leave  no  visible  trace. 

Treatment. — Common  salt  water  injections  or 
fresh  garlic  infusions  given  for  a  night  or  two  at  bed- 
time, is  generally  radical  treatment,  but  the  physician 
himself  may  have  to  administer  in  some  cases  an 
enema  of  bichloride  of  mercury  (one  grain  to  four 
ounces  of  water)  and  follow  it  in  a  few  minutes  with 
an  injection  of  plain  cold  water. 

2.  Ascaris  lumbricoides,  the  round  or  stomach 
worm,  is  somewhat  longer  than  the  common  angle 
worm;  /.  e.,  four  to  twelve  inches,  whiter  in  color, 
and  more  tapering  at  its  extremities.  Its  ova  are 
quite  indestructible  and  may  remain  dormant  a  long 
time,  probably  until  conditions  favorable  to  its  life 
are  found  in  some  human  or  other  animal,  being  quite 
partial  to  the  small  intestine  of  children  from  three 
to  ten  years  old.  Its  migrations  into  the  large  intes- 
tine, out  through  the  anus,  or  up  into  the  hepatic 
ducts,  stomach,  or  oesophagus,  are  its  most  trouble- 
some and  even  dangerous  habits,  for  in  rare  cases  it 
has  perforated  the  intestine  and  been  found  in  the 
cavity  of  the  abdomen  in  large  numbers.  While  the 
females  of  this  species  are  exceedingly  prolific,  each 
individual  containing  millions  of  eggs,  the  numbers 
of  mature  worms  in  each  individual  patient  may  not 
necessarily  exceed  a  half  dozen  in  order  to  produce 
marked  symptoms.  Convulsions  and  "worm  fevers  " 
simulating  gastritis  are  not  tmcommon  results  of 
their  irritation  in  the  intestines  and  stomach,  but  the 
many  nervous  conditions,  such  as  picking  the  nose, 


DISEASES    OF    THE    DIGESTIVE    TRACT.  1 79 

choreic  movements,  night-mare,  and  the  colicky  pains, 
diarrhoea,  feeble  appetite,  milky  urine,  etc.,  attrib- 
uted to  worms  are  by  no  means  diagnostic  of  anything 
but  impaired  digestion,  which  may  or  may  not  be  as- 
sociated with  worms.  The  presence  of  worms  or 
their  ova  (as  seen  under  the  microscope)  in  the  evac- 
uations or  about  the  anus  are  the  only  true  signs  of 
these  or  any  other  variety  of  parasites. 

Treatment.  —  Santonine,  the  active  crystalline 
principle  of  artemisia  santonica,  cina,  or  German 
wormseed,  is  the  most  efficient  remedy  for  these 
lumbricoid  worms.  It  may  be  given  at  bedtime  in 
from  one  to  three  grains  in  powder,  lozenges,  or 
spread  on  bread  and  butter,  and  followed  by  castor 
oil  or  some  other  efficient  laxative  in  the  morning ; 
but  as  nearly  all  authorities  record  some  occasional 
poisoning  symptoms  from  such  doses,  the  exhibition 
of  our  first  or  second  decimal  trituration  three  or  four 
times  a  day  for  three  or  four  days  is  safer  and  just  as 
efficient.  Prof.  Demme  prefers  to  administer  santo- 
nine  in  a  slightly  oleaginous  solution,  one-half  grain 
to  one  ounce  of  olive  oil,  and  needs  no  laxative  there- 
after. The  writer  obtains  thorough  results  from  a 
large  powder  of  the  Ix  at  night  and  the  use  of  cina 
30  every  two  hours  through  the  day  for  a  few  days, 
such  treatment  bringing  the  worms  and  allaying 
all  reflex  symptoms  in  the  meantime.  Without  this 
dynamic  treatment  of  such  cases,  followed  by  proper 
food,  a  delicate  child  is  left  weaker  and  worse  off  for 
the  time  being  than  when  suffering  from  worms. 

It  should  be  remembered  that  the  comparatively 
rare  tubercular  peritonitis  has  been  treated  in  its 
earlier  stages  as  "only  stomach  worms." 


l8o  PRESENT    STATUS    OF    PEDIATRICS. 

3.  Trichocephalus  dispar,  or  so-called  whip 
worm  from  its  shape,  is  an  occasional  inhabitant  of 
the  coecum  or  ilium,  and  of  little  clinical  importance 
because  of  its  rarity  in  childhood  and  lack  of  peculiar 
symptoms.  Santonine  is  probably  the  most  efficient 
vermifuge  for  this  variety. 

4.  Tape  Worms.  —  These  parasites  are  never 
found  in  nurslings  and  rarely  in  children.  The  tape 
worm,  of  which  there  are  several  varieties,  is  an  her- 
maphrodite, each  segment  containing  the  two  sexual 
organs,  and  develops  from  a  small  head  or  scolex 
about  the  size  of  a  pin  head,  segment  after  segment 
by  a  sort  of  budding  process,  the  segments  growing 
larger  and  more  matured  as  they  become  further  re- 
moved from  the  head,  the  whole  worm  attaining  a 
length  varying  from  twelve  to  twenty-four  feet.  The 
two  common  varieties  in  this  country  are  the  taenia 
solium,  or  pork  tape  worm,  and  the  taenia  saginata,  or 
medio-canellata,  or  beef  tape  worm.  The  taenia  so- 
lium, so-called  because  nearly  always  found  alone, 
has  a  circlet  of  booklets  about  its  head  to  distinguish 
it  from,  the  other  taenia,  and  is  longer  with  thinner  and 
more  slender  segments.  These  segments  in  the  stools 
or  at  the  anus  are  the  usual  evidences  of  the  resi- 
dence of  the  parasites,  and  their  breaking  off  even 
in  long  sections  by  no  means  interferes  with  its  life. 
The  head  must  be  secured  by  the  treatment,  else  two 
or  three  months  time  will  bring  down  more  segments 
as  evidence  that  the  parasite  still  lives  and  the  treat- 
ment must  be  gone  over  again. 

Treatment. — Almost  all  taenicides  are  necessarily 
poisonous  and  irritating,  and  are  therefore  to  be  used 


DISEASES    OF    THE    DIGESTIVE    TRACT.  l8l 

with  care,  especially  in  children.  Among  them  are 
the  following:  Male  fern  {filix  mas)^  Y-z  drachm  of 
the  ethereal  extract^  the  tannate  and  sulphate  of  pel- 
letter  in  ^  the  active  principle  of  the  pomegranate; 
konsso^  I  to  2  drachms  of  the  powder;  kamala,  in  i 
to  2  drachms  in  a  gum  arable  solution,  may  be  re- 
peated several  times  and  requires  no  purgative  to  fol- 
low; an  emulsion"  of  pumpkin  seeds  (2  ounces  of 
seeds  rubbed  up  in  a  pint  of  water,  strained,  and  10 
to  15  minims  of  snlpJmric  ether  added),  causes  no 
unpleasant  or  injurious  effects.  With  all  these  reme- 
dies a  low  diet  of  light  liquid  food  should  precede  for 
a  few  days,  and  an  active  purgative,  as  castor  oil^  fol- 
low after  a  few  hours  to  expel  the  dead  parasite,  ex- 
cept with  kamala  and  pumpkin  seeds,  which  are  of 
themselves  sufficiently  purgative.  The  destruction 
and  expulsion  of  intestinal  parasites  is  a  purely  me- 
chanical process,  outside  of  homoeopathic  therapeu- 
tics, but  many  of  our  remedies  such  as  cina,  spigelia, 
tgnatia,  sulphur,  etc. ,  give  relief  to  the  symptoms  of 
irritation  present  before  and  after  the  removal  of  the 
unwelcome  guests.     (See  Tooker,  pp.  216,  217.) 


l82  PRESENT    STATUS   OF    PEDIATRICS. 


CHAPTER  VIII. 


DISEASES  OF  THE  URINARY  ORGANS. 

BY    ALFRED    P.   HANCHETT,  M.  D. ,   COUNCIL   BLUFFS,   IOWA. 

In  presenting  the  present  status  of  diseases  of  the 
urinary  organs  in  children  I  have  culled  from  several 
recent  works  upon  this  subject;  also  from  the  jour- 
nals and  fragmentary  writings  of  the  past  twelve 
months  whatever  is  of  special  value  or  interest,  in- 
cluding with  the  little  that  is  new  much,  of  course, 
that  is  old.  For  the  sake  of  brevity,  and  also  be- 
cause practically  the  whole  paper  is  a  series  of  se- 
lected extracts,  I  omit  all  reference  to  special  authori- 
ties. The  space  at  my  disposal  permits  but  the  brief- 
est resume  of  the  more  important  diseases  of  the 
urinary  organs;  if,  therefore,  some  subjects  are  alto- 
gether omitted  that  properly  belong  here,  or  if  ques- 
tions and  consideration^  of  importance  seem  to  have 
been  slighted,  kindly  remember  a  ten-page  article 
cannot  possibly  do  full  justice  to  a  topic  which  is 
often  treated  upon  in  a  volume  of  a  thousand  pages. 

THE  URINE.  — Quantity.  — The  average  quan- 
tity of  urine  passed  in  twenty-four  hours  by  infants 
during  the  first  ten  days  of  life  varies  from  four  to 
ten  ounces.  It  increases  rapidly  during  this  period, 
but  more  slowly  during  the  remainder  of  the  first 


DISEASES    OF    THE    URINARY    ORGANS.  183 

month,  at  the  end  of  which  time  it  is  from  six  to 
twelve  ounces,  and  by  the  end  of  the  first  year  it  is 
ten  to  fourteen  ounces.  During  the  first  seven  years 
of  child  life  a  fair  average  quantity  is  one  fluid  ounce 
for  each  pound  of  the  child's  weight.  If  it  varies 
greatly  and  persistently  from  the  above,  it  is  because 
the  child  is  sick,  or  improperly  fed,  and  the  cause 
should  be  determined. 

To  collect  the  urine  of  young  children  accurately, 
secure  two  fair  sized  sponges,  cleanse  thoroughly,  and 
after  drying,  weigh.  Place  one  over  the  genital  or- 
gans and  secure  with  napkin.  When  wet  remove  and 
weigh,  and  place  the  dry  one  as  before.  Thus  alter- 
nately weighing  and  changing  for  twenty-four  hours 
gives  the  quantity,  and  as  much  as  is  needed  for  ex- 
amination can  be  expressed  from  the  sponges. 

Character. — The  urine  of  very  young  children  is 
generally  clear  and  watery,  though  if  first  micturi- 
tion is  delayed  it  will  be  slightly  yellow,  or  if  the  in- 
fant becomes  jaundiced,  the  bile  escaping  in  the  urine 
gives  it  a  darker  color.  The  odor  will  be  only  slightly 
urinous. 

The  specific  g'ravity  at  birth  is  light,  varying 
from  1.002  to  1. 010,  and  not  often  more  than  1.012 
during  childhood-.  Its  reaction  should  be  neutral, 
or,  if  retained  longer  than  usual,  feebly  acid.  The 
healthy  infant  will  void  about  one  and  three-fourth 
grains  urea  to  the  pound  of  its  weight  every  twenty- 
four  hours. 

Albuminuria. — The  presence  of  albumin  in  the 
urine  will  indicate  one  of  the  following  conditions : 

I.   Functional  albuminuria,  or  cause  unknown. 


1 84  PRESENT    STATUS    OF    PEDIATRICS. 

2.  Some  febrile  condition. 

3.  The  presence  of  blood,  pus,  chyle,  or  bile. 

4.  Pressure  on  renal  vessels,  as  tumor,  etc. 

5.  Nephritis. 

6.  Complicating  epilepsy,  or  other  convulsions. 

7.  Poisoning,  as  cantharides,  or  turpentine. 
FUNCTIONAL  DISEASES  OF  THE  BLADDER.— 

The  progress  made  in  the  study  of  nervous  diseases, 
especially  in  the  school  of  Charcot,  has  had  the  effect 
to  direct  more  attention  to  the  intimate  relation  ex- 
isting between  the  nervous  system  and  many  vesical 
disorders,  both  with  and  without  recognizable  lesions 
of  the  spinal  cord.  The  following  classification  is 
nearly  the  same  as  that  given  by  M.  Tuffier  of  func- 
tional troubles  of  the  bladder  dependent  upon  some 
defect  in  the  innervation  of  that  organ  : 

1.  Due  to  actual  structural  diseases  of  the 
nervous  system.  —  Under  this  head  would  come 
ataxia,  lesions  of  the  spinal  cord  and  brain,  localized 
sclerosis,  general  paralysis,  and  insanity.  In  these 
conditions  there  may  be  motor  paralysis  without  re- 
tention ;  paralysis  with  partial  or  complete  retention, 
or  incontinence,  which  may  be  intermittent,  the  over- 
flow of  an  overfilled  bladder,  or  due  to  an  irritable 
bladder  leading  to  a  discharge  as  soon  as  the  patient 
makes  a  move  to  urinate,  or  to  an  urgent  tenesmus 
accompanied  by  cystalgia. 

2.  Disturbances  due  to  epilepsy,  the  chief  of 
which  is  incontinence.  It  differs  from  common  noc- 
turnal incontinence  by  occurring  at  longer  intervals, 
and  by  the  patient  waking  with  a  feeling  of  extreme 
weakness,  exhaustion,  and  weight  in  the  head. 


DISEASES    OF    THE    URINARY    ORGANS.  185 

3.  Connected  with  congenital  malformations; 
and  (4),  those  due  to  lesions  of  neig'hboring'  or- 
gans, often  described  as  the  irritable  bladder.  The 
malformations  may  be  contracted  external  urinary 
meatus,  narrow  adherent  or  elongated  foreskin,  ad- 
herent hood  to  clitoris,  and  lesions  of  neighboring-  or- 
gans might  be  fissure  of  the  anus,  hemorrhoids,  or 
operations  on  the  rectum. 

5.  Due  to  lesions  of  the  bladder,  as  vesical  cal- 
culi or  tumor,  and  fissure  in  the  female  urethra,  pro- 
ducing vesical  tenesmus. 

6.  Due  to  the  condition  of  the  urine,  as  the 
large  quantity  of  limpid  urine  in  the  hysterical  pa- 
tient, the  excessive  quantities  of  saccharine  urine  and 
its  frequent  accompanying  pruritus  of  the  diabetic 
patient,  the  excess  of  urates  in  the  gouty,  the  phos- 
phatic  urine  of  the  neurotic,  and  the  extremely  acid 
urine  so  irritable  to  the  bladder. 

7.  Idiopathic  functional  disturbances  of  the 
bladder  attended  by  cystalgia  and  spasms  of  the  ves- 
ical muscular  tissue  and  the  urethral  sphincter. 

8.  Vesical  troubles  of  mental  origin.  The 
enormous  influence  of  the  mind  over  the  functions  of 
the  bladder  is  proverbial.  The  remarkable  experi- 
ences of  Mosso  and  Pellacane  have  proved  that  every 
thought,  every  emotion,  as  well  as  every  sensory  ex- 
citation, determines  an  immediate  contraction  of  the 
vesical  muscular  tissue ;  and  Janet  has  shown  that  if 
the  thoughts  have  reference  to  micturition,  the  conse- 
quent contraction  of  the  bladder  is  the  more  intense. 
They  are  powerful  excito-reflexes  of  the  nerves  of  the 
bladder. 


l86  PRESENT    STATUS    OF    PEDIATRICS. 

The  cause  of  these  psychological  troubles  is  an 
over-anxiety  about  micturition,  which  may  exist  quite 
independently  of  the  least  physical  basis,  or  may  have 
as  its  foundation  some  slight  but  real  urethro -vesical 
trouble.  As  a  result  of  this  mental  condition  the 
bladder  becomes  irritable,  micturition  is  frequent, 
and  there  is  an  abnormal  amount  of  urine  secreted. 
That  the  polyuria,  as  well  as  the  frequency  of  mictu- 
rition, is  due  to  mental  influence  is  proven  by  the  fact 
that  if  the  mind  is  engaged  and  interested  both  cease 
as  they  do  during  sleep.  The  patient  may  pass  water 
fifty  times  a  day  yet  sleep  all  through  the  night.  A 
greatly  increased  capacity  of  the  bladder  is  proven  to 
exist  by  injections  of  warm  water,  and  yet  the  cathe- 
ter left  in  the  bladder  as  a  drain  tube  does  not  remove 
the  desire  to  pass  water.  When  this  goes  on  to  an 
extreme  the  polyuria  occurs  at  night,  and  they  either 
sleep  lightly,  rising  often  to  pass  urine,  or  sleep 
soundly,  passing  the  urine  in  bed.  This  is  one  of  the 
varieties  probably  most  common  of  nocturnal  inconti- 
nence in  children.  This  form  of  incontinence  is  not 
diurnal,  for  no  matter  how  frequent  the  desire  to  uri- 
nate there  will  be  no  loss  of  control.  Diurnal  incon- 
tinence is  not  due  to  psychological  causes,  but  trouble 
of  a  different  nature. 

Another  form  of  functional  disturbance  from  men- 
tal causes  is  urethral  spasm,  manifested  during  mic- 
turition. This  is  that  condition  so  happily  described 
by  Paget  as  ''stammering  of  the  bladder,"  which 
renders  the  person  incapable  of  micturating  in  the 
presence  of  others;  or  the  inability  to  start  the  flow 
without  the  mental  stimulus  of  some  such  sound  as 
that  of  running  water. 


DISEASES    OF    THE    URINARY    ORGANS,  187 

ENURESIS. — Enuresis  is  the  disorder  in  the  uri- 
nary tract,  regarding  which  every  physician  is  most 
frequently  consulted.  It  is  but  a  symptom,  how- 
ever, the  causes  of  which  are  many.  It  is  often  de- 
pendent upon  a  persistent  infantile  weakness  in  the 
neck  of  the  bladder  or  sphincter  muscle,  or  it  may  be 
caused  by  reflex  irritability  of  the  bladder  or  any  of 
the  pelvic  organs.  Among  the  causes  of  reflex  irrita- 
bility may  be  noted  fissure  of  the  neck  of  the  bladder, 
vesical  calculus  or  tumor,  and  the  irritating  nature 
of  the  urine,  as  increasedly  acid  or  alkaline;  rectal 
irritation,  as  fissure,  eczema,  or  pin  worms;  hyper- 
aesthetic  condition  of  the  sexual  organs  dependent 
on  stricture,  constricted  or  adherent  foreskin,  or  ad- 
herent hood  of  the  clitoris,  or  the  psychical  effect  of 
dreams.  Masturbation,  by  increasing  the  sensitive- 
ness of  the  prostatic  portion  of  the  neck  of  the  blad- 
der, may  result  in  enuresis. 

Children  suffering  from  nocturnal  enuresis  only, 
who  have  complete  control  of  the  urinary  functions 
during  the  day,  are  in  a  majority  of  cases  victims  of 
the  psychical  form  of  this  disorder.  It  is  clear  in 
such  cases  that  the  bladder  is  in  a  healthy  state  and 
will  retain  a  normal  amount  of  urine,  for,  as  it  fills 
and  produces  the  usual  pressure,  instead  of  waking 
the  child,  it  induces  a  dream  which  is  influenced  by  a 
dominating  fear  that  an  accident  will  happen.  He 
will  dream  of  rain,  or  running  water,  or  that  he  is  in 
some  suitable  place  for  passing  urine,  and  will  only 
awaken  to  fi.nd  himself  saturated.  This  form  of 
trouble  can  often  be  corrected  by  suitable  remedies, 
but  it  is  sure  to  disappear  at  puberty,  the  sexual  de- 


1 88  PRESENT    STATUS    OF    PEDIATRICS. 

velopment  changing  the  psychological  condition.  A 
class  of  cases  in  boys  recover  with  the  development 
of  the  prostate  at  puberty. 

If  periodicity  of  incontinence  is  a  marked  feature, 
then  it  is  apt  to  be  neurotic  in  origin.  It  may  accom- 
pany and  be  occasioned  by  nocturnal  epilepsy,  or 
night  terrors. 

Diurnal  incontinence,  I  believe,  is  generally  due  to 
insufficiency  of  the  sphincter  muscle,  permitting  a 
few  drops  of  urine  to  enter  the  upper  part  of  the 
urethra ;  this  being  followed  by  more  and  more  keeps 
up  a  continuous  dribbling.  The  parts  being  in  a  par- 
tially anaesthetic  condition,  the  child  is  scarcely  con- 
scious of  its  escape.  It  is  often  found  in  children  who 
are  bright  and  overactive,  though  occasionally  oc- 
curring in  the  dull  and  stupid. 

The  treatment  must  first  be  directed  to  the  reflex 
trouble,  if  such  be  found  to  exist.  Examine  care- 
fully for  any  orificial  irritation,  and  correct  whatever 
is  found.  Collect  the  urine  and  learn  the  exact  amoimt 
secreted  in  twenty-four  hours.  Test  carefully  as  to 
excessive  acidity  or  alkalinity ;  also  for  albumin  and 
sugar ;  examine  for  uric  acid  crystals,  also  calcic  oxa- 
late, and  if  any  of  them  are  found,  select  a  diet  to 
aid  in  eliminating  the  abnormal  property.  In  most 
of  this  class  of  troubles  it  is  well  to  largely  avoid 
sweet  and  starchy  food,  and  to  use  meat  sparingly, 
but  green  vegetables,  eggs,  milk,  poultry,  and  fish 
may  be  used  freely.  In  the  line  of  remedial  treat- 
ment, almost  any  remedy  in  the  materia  medica  may 
be  indicated  in  cases  dependent  upon  some  dyscrasia 
or  constitutional  peculiarity. 


DISEASES    OF    THE    URINARY    ORGANS.  1 89 

Aconite  is  indicated  in  cases  of  neurotic  origin. 
Patient  excitable,  frightened,  awakes  in  state  of  ter- 
ror, restless  and  nervous,  with  some  fever. 

Belladonna  or  gelscniiuni  will  often  be  helpful  in 
cases  dependent  on  insufficiency  of  the  sphincter,  un- 
conscious continual  escape,  day  and  night  alike;  or 
worse  during  the  day  often. 

Cina,  santonine,  or  spigelia  will  be  useful  when  the 
trouble  is  caused  by  pin  worms. 

When  an  irritable  bladder  is  the  principal  trouble, 
urination  frequent  but  under  the  child's  control 
through  the  day,  but  involuntary  at  night,  the  child 
complaining  of  discomfort  or  pain  upon  urinating, 
study  cantharis,  cJiiiiiapJiila^  canstictivi  apis,  and  a?'- 
seniciim  album. 

When*  the  urine  is  dark  and  offensive,  containing 
uric  acid  or  calcic  oxalate  crystals,  is  chiefly  trouble- 
some afternoons  and  at  night,  think  of  benzoic  acid, 
lithiini  carboniciim,  lycopodiuni,  sepia,  or  mercury. 

If  the  child  is  illy  nourished,  puny,  frequently  ill 
with  numerous  minor  ailments,  especially  if  a  child 
of  scrofulous  parents,  study  sulphur  or  psorinurn, — 
give  a  few  doses  of  the  one  best  indicated  and  await 
the  outcome.     I  have  seen  amazing  results. 

LITHEMIA. — This  is  often  known  as  the  uric  acid 
diathesis.  In  children  it  is  frequently  the  result  of 
prolonged  illness.  Just  where  or  how  the  uric  acid  is 
produced  is  not  known. 

The  symptoms  of  lithemia  in  children  are  of  two 
classes :  Those  due  to  the  presence  of  uric  acid  in  the 
system,  and  those  due  to  its  excretion  from  the  sys- 
tem.    When   there  is  an  excess  of  uric  acid  in  the 


190  PRESENT    STATUS    OF    PEDIATRICS. 

system,  the  little  patient  is  apt  to  be  precocious,  nerv- 
ous, restless,  excitable, — one  extreme  or  the  other. 
Wakeful  at  night;  talks  in  his  sleep;  dainty  eater; 
craves  indigestible  food;  very  sensitive  to  cold  or 
dampness.  Perspires  too  freely ;  has  damp  cold  hands 
and  feet ;  irritation  of  the  larynx,  pharynx,  or  tonsils. 
Tendency  to  catarrh  of  the  stomach  and  bowels,  and 
to  enlargement  of  the  liver  and  spleen. 

AVith  the  excretion  of  uric  acid  the  symptoms  are 
very  different.  Pain  is  pre-eminent.  Renal  colic 
may  be  mistaken  -for  stomach-ache.  The  pain  will 
be  intermittent,  and  may  be  located  anywhere  in  the 
urinary  tract.  The  paroxysms  will  be  very  sharp, 
and  may  be  attended  by  hematuria,  shivering,  nausea, 
and  vomiting.  These  patients  are  apt  to  drink  water 
immoderately  and  sweat  profusely,  reducing  the  quan- 
tity of  urine  secreted  and  leaving  it  overloaded  with 
the  solids.  The  urine  may  be  clear  when  passed,  but 
soon  becomes  cloudy  or  covered  with  a  film  or  pelli- 
cle ;  or  after  standing  a  few  hours,  a  sedimentary  de- 
posit of  free  uric  acid  will  give  the  characteristic  brick 
dust  stain  in  the  vessel. 

Treatment. — In  the  treatment  of  lithemia  the  diet 
and  hygienic  care  of  the  patient  are  of  the  greatest 
importance.  Sweets  and  starchy  foods  should  be 
used  moderately ;  but  little  meat  is  to  be  taken ;  fresh 
fruits,  green  vegetables,  milk,  eggs,  fish,  and  poultry 
may  be  taken  freely.  Exercise  should  be  taken  regu- 
larly, avoiding  too  great  violence;  cold  baths  are 
good  taken  upon  rising  in  the  morning,  followed  by 
vigorous  rubbing ;  plenty  of  sleep,  and  water  freely 
at  meal  time.     Special  stress  is  placed  upon  the  im- 


DISEASES    OF    THE    URINARY    ORGANS.  19I 

portance  of  these  children  getting  plenty  of  sleep,  as 
it  seems  to  be  the  best  antidote  to  the  uric  acid  poison 
known.  The  leading  remedies  are  lycopodium^  bcr- 
bcris^  lithhim  carbonicum^  calcarea  carbonica,  nux 
vomica^  sepia,  benzoic  acid,  aliimimuji,  sulphur,  and 
psorimun. 

RENAL  CALCULI.— Another  disorder  frequently 
met  within  children  is  gravel,  or  renal  calculi.  There 
are  three  different  classes  of  vesical  calculi :  Uric  acid 
and  its  combinations,  phosphoric  acid  and  its  combi- 
nations, and  the  oxalate  of  lime.  The  uric  acid  and 
urates  constitute  about  three-fifths  of  the  cases.  The 
usual  symptoms  of  stone  in  young  children  are  pro- 
lapsus ani,  priapism,  bloody  urine,  sudden  stoppage 
in  the  flow  of  urine,  brown  or  red  sandy  sediment. 
The  pain  varies  in  its  situation  and  character,  but  is 
often  an  aching  behind  the  symphysis,  in  the  peri- 
neum, or  along  the  ureters  to  the  end  of  the  penis ; 
aggravated  by  exercise,  and  at  the  end  gf  micturition 
relieved  by  lying  down.  To  determine  absolutely 
the  presence  or  absence  of  stone  in  the  bladder,  noth- 
ing is  equal  to  the  steel  sound. 

Sir  Henry  Thompson's  records  show  that  of  1,827 
cases  of  lithotomy  m  England,  over  fifty  per  cent  were 
in  children  under  thirteen  years  of  age.  He  also 
noted  that  the  great  majority  of  the  cases  in  children 
were  from  the  poorer  homes,  rarely  meeting  a  case 
among  the  children  of  the  better  classes. 

The  treatment  consists  in  the  use  of  large  quan- 
tities of  water,  the  lithia  waters  being  recommended 
by  many  writers,  frequent  warm  baths,  non-nitroge- 
nous diet,  and  the  use  of  some  alkali,  as  sodium  pJws- 


192  PRESENT    STATUS    OF    PEDIATRICS. 

pJiate^  or  the  bcnzoatcs,  in  small  but  material  doses; 
or  if  the  stone  has  attained  much  size,  some  surgical 
measure  for  its  removal  will  be  necessary. 

ACUTE  NEPHRITIS.— Acute  inflammation  of  the 
kidneys  is  generally  a  secondary  trouble,  following 
scarlet  fever,  diphtheria,  typhoid  fever,  or  almost  any 
of  the  acute  diseases.  Some  poisions  have  been 
known  to  cause  it,  as  mercury  and  turpentine,  and  it 
occasionally  results  from  exposure  to  cold. 

Symptomatolog'y. — The  first  symptoms  in  post- 
scarlatinal nephritis  are  generally  seen  from  the  four- 
teenth to  the  twenty- first  da)^  after  the  onset  of  the 
primary  disease,  and  when  desquamation  is  vrell  ad- 
vanced, the  temperature  having  become  normal,  or 
nearly  so.  There  will  be  a  little  return  of  fever, 
headache,  pallor,  malaise,  and  possibly  convulsions. 
A  slight  puffiness  below  the  eyes  and  about  the  ankles 
will  soon  be  noticeable,  and  the  secretion  of  urine  di- 
minished. CEdema  will  increase  rapidly,  general  ana- 
sarca, great  dulness,  even  stupor,  difficult  breathing, 
and  a  tormenting  spasmodic  cough  will  soon  follow. 
The  urine  will  now  be  loaded  with  albumin,  and  of  a 
light  specific  gravity.  The  heart's  action  will  be 
labored  and  often  irregular. 

Acute  primary  nephritis  in  children  may  easily  be 
overlooked  in  the  early  stage ;  it  is  therefore  impor- 
tant to  examine  the  urine  in  every  obscure  case,  espe- 
cially so  if  there  be  continuous  rise  of  temperature 
not  clearly  accounted  for. 

The  prog'nosis  in  acute  nephritis  is  reasonably 
favorable  if  discovered  early,  but  it  will  require  the 
closest   attention   and    careful   nursine.       Favorable 


DISEASES   OF    THE    URINARY    ORGANS.  193 

symptoms  are  increased  flow  of  urine,  decrease  in 
albumin,  improved  heart  action,  slower  and  deeper 
respiration. 

Treatment. — A  milk  diet  in  scarlet  fever  and  the 
avoidance  of  all  exercise  or  exposure  until  after  the 
third  week  will  generally  prevent  this  and  all  other 
sequelce  so  much  to  be  dreaded.  If,  however,  albu- 
minuria is  present,  the  child  should  be  put  to  bed 
in  blankets;  he  should  have  frequent  hot  sponge 
baths,  followed  by  vigorous  rubbings,  and  the  tem- 
perature of  the  room  should  be  carefully  kept  at  70 
to  75  degrees  F.  The  diet  should  be  light  but  nutri- 
tious ;  milk,  gruels,  rice,  arrow  root,  etc. 

The  remedies  commonly  found  helpful  are  mercu- 
riiis  corrosiviiSy  terebinthina,  apis,  arsencium  alburn, 
cantJiaris,  ferrtivi  pJwsphoriciim,  and  digitalis,  though 
any  remedy  that  is  indicated  by  the  symptoms  of 
that  particular  case  will  be  curative. 

DIABETES  MELLITUS.— Diabetes  mellitus  is  oc- 
casionally met  with  in  children,  yet  so  rare  is  it 
that  four  writers  whose  reported  cases  collectively 
number  1,838,  in  patients  of  all  ages,  report  but  six 
in  children  under  eight,  and  but  nineteen  in  those 
under  twenty  years  of  age.  The  question  of  its  pa- 
thology is  yet  unsettled,  but  I  believe  it  will  ultimately 
be  proven  to  be  due  to  a  suppression  of  some  other 
and  more  superficial  disease  by  excessive  drugging, 
and  that  when  this  is  more  fully  understood,  and 
treatment  employed  that  will  meet  this  condition  we 
shall  have  more  reports  of  cured  cases.  The  chief 
characteristic  symptoms  are  glycosuria,  polyuria, 
polydipsia,  and  bulimia. 

14 


194  PRESENT    STATUS    OF    PEDIATRICS. 

Complications  often  appear  in  diabetic  patients 
with  little  warning,  and  may  be  coma,  albuminuria, 
phlegmonous,  and  gangrenous  inflammations,  pruri- 
tus, eczema,  cystitis,  disturbed  vision,  and  various 
other  disorders. 

The  prognosis  should  be  guarded,  as  a  large  per- 
centage of  the  cases  are  fatal,  and  it  runs  a  more 
rapid  course  in  children  generally  than  in  adults. 

Treatment. — Many  authorities  recommend  highly 
what  is  styled  the  diabetic  diet,  others  do  not  adhere 
so  closely  to  it,  and  after  considerable  observation  of 
cases  treated  both  ways  I  am  inclined  to  allow  nearly 
the  usual  diet,  eliminating  only  the  excessive  use  of 
sweets. 

DIABETES  INSIPIDUS.— This  is  similar  to  dia- 
betes mellitus,  in  the  quantity  of  urine,  excessive 
thirst  and  appetite,  and  emaciation,  but  the  urine  is 
of  light  specific  gravity  and  free  from  sugar.  This 
disease  is  common  in  childhood. 

Etiology. — ^lany  causes  are  assigned,  which  may 
be  taken  to  indicate  that  the  etiology  is  not  under- 
stood. The  same  maybe  said  of  its  pathology.  The 
kidneys  are  sometimes  found  diseased,  but  oftener 
normal. 

Symptomatology.  — The  quantity  of  urine  is 
sometimes  enormous,  as  much  as  thirty  pints  in 
twenty-four  hours,  though  from  ten  to  fifteen  is  about 
an  average.  The  specific  gravity  maybe  from  1.002 
to  1. 010.  The  course  of  the  disease  is  very  uncer- 
tain, some  patients  living  for  years  in  comparative 
comfort,  and  dying  of  some  other  trouble,  diabetes 
insipidus  rarely  proving  fatal  of  itself. 


DISEASES    OF    THE    URINARY    ORGANS.  195 

Treatment. — In  the  treatment  of  these  cases  look 
well  after  the  general  health.  Nutritious  food,  fre- 
quent baths,  moderate  but  regular  exercise,  and  the 
remedy  covering  the  prominent  and  peculiar  symp- 
toms of  the  case  in  hand  will  generally  cure.  Reme- 
dies to  be  considered  are  arsenicuin  album,  apis, 
apocynuin,  Jielonias,  fcrruin,  mix  vomica,  ignatia, 
psorimim,  silicea,  and  snip  J  iter. 


196  PRESENT    STATUS    OF    PEDIATRICS. 


CHAPTER  IX. 


•  SKIN  DISEASES. 

BY  A.  M.  LINN,  A.  M. ,  M.  D. ,  MEMBER  AMERICAN  INSTITUTE  OF 
HDMCEOPATHY  AND  HAHNEMANN  ASSOCIATION  OF  IOWA;  PHY- 
SICIAN   TO    HOME   FOR    FRIENDLESS,   DES    MOINES,   IOWA. 

ERYTHEMA. — Erythema  is  a  hyperaemia  of  the 
skin,  varying  from  a  simple  congestion  to  an  acute 
inflammation.  It  consists  of  irregular,  superficial  red 
patches  accompanied  by  smarting,  tingling,  and  mild 
fever.  Two  types  obtain :  Erythema  hyperaemicum, 
a  simple  congestion,  and  erythema  exudativum,  dis- 
tinguished by  a  perceptible  exudate. 

Erythema  simplex  is  the  result  of  chafing  and  of 
either  cold  or  heat  or  of  some  external  irritant.  It 
is  mild  in  form,  without  constitutional  symptoms. 
No  treatment  is  needed  beyond  removal  of  the  excit- 
ing cause  and  the  application  of  some  soothing  lotion, 
followed  by  dusting  with  lycopodiiim  powder. 

Erythema  intertrigo  is  a  form  of  erythema  often 
seen  in  fat  children  in  folds  of  skin  about  the  neck 
and  joints.  It  is  due  to  the  heat  and  secretions  re- 
tained in  the  creases  of  the  skin,  and  occurs  espe- 
cially in  the  heat  of  summer.  Cleanliness  and  sepa- 
ration of  approximating  surfaces  is  usually  sufficient 
to  effect  a  prompt  cure. 


SKIN    DISEASES.  I97 

Erythema  perino,  or  commonly  called  chilblain, 
results  from  exposure  to  cold  and  wet,  and  then  sud- 
denly heating  the  affected  parts,  usually  the  feet  and 
hands.  The  parts  thus  subjected  to  the  sudden  ex- 
tremes of  temperature  become  shining  red,  swollen, 
itch  and  bum  severely.  In  chronic  cases  they  assume 
a  bluish  tint,  and  sometimes  suppurate. 

Treatment. — Topical  application  of  calendula  ce- 
rate and  lotions  of  agariciis  and  Pulsatilla  are  recom- 
mended. Remedies  useful  are  agaricus^  belladonna^ 
petroleum,  Pulsatilla,  rhus  toxicodendron. 

Erythema  fuga  is  a  fleeting  form  occurring  mostly 
in  children  from  digestive  disturbances  and  manifests 
itself  most  frequently  on  the  face. 

Erythema  neonatorum  affects  the  new-born  in- 
fants during  the  first  few  days  of  its  existence.  It  is 
due  to  irritation  of  the  sensitive  skin.  It  is  charac- 
terized by  minute  red  papules  over  the  congested  sur- 
face, usually  the  breast  and  neck,  and  fades  in  a  short 
time.  The  protection  of  the  skin  by  mild  lotions 
and  the  avoidance  of  all  irritation  is  the  only  treat- 
ment needed. 

Erythema  multiforme  is  usually  preceded  by 
some  systemic  disturbances  and  mild  fever  with  gas- 
tric irritation.  Some  authors  maintain  that  the  cu- 
taneous eruption  is  preceded  by  erythema  of  the 
pharynx  and  larynx.  The  backs  of  the  hands  and 
feet  are  first  affected,  and  it  gradually  involves  the 
trunk  and  limbs,  fading  and  reappearing  again.  It  is 
not  so  frequently  seen  in  children,  but  when  thus  oc- 
curring it  may  develop  in  severe  form  and  the  vesi- 
cles may  become  purulent  and  leave  cicatrices.     The 


198  PRESENT    STATUS    OF    PEDIATRICS. 

disease  usually  lasts  from  a  fortnight  to  a  month,  but 
may  not  cease  for  many  months.  During  the  erup- 
tion there  is  some  burning  and  itching. 

Remedies  are  belladonna^  bryonia,  mcrcuriiis  solu- 
bilis,  mix  vomica,  Pulsatilla,  nstilago,  cBtJiusa,  cJiloral 
Jiydrate,  cJielidoninni  inajus. 

Erythema  nodosum  should  properly  be  regarded 
as  a  variety  of  erythema  multiforme,  and  often  occurs 
simultaneously.  It  frequently  affects  children  and 
appears  as  round  or  oval  swellings  from  the  size  of  a 
filbert  to  a  walnut  on  the  anterior  part  of  the  legs. 
They  vary  in  number  from  one  to  a  dozen,  are  usu- 
ally quite  painful,  and  when  oval  in  form  their  long 
axis  is  vertical.  It  is  preceded  by  rheumatic  and 
tibial  pains  and  is  due  to  mal-nutrition.  This  form 
usually  appears  in  crops  lasting  from  two  to  three 
weeks. 

Treatment. — Topical  application  of  haniauiclis  is 
usually  helpful.  Kippax  recommends  rJius  venenata 
and  arnica,  ptelea,  and  trifoliuni. 

ROSEOLA.— (Syn.  Rose  Rash;  False  Measles.)— 
This  cutaneous  affection  occurs  usually  in  children 
and  almost  always  is  secondary  to  some  other  disor- 
der, usually  gastric  or  constitutional,  or  occasioned  by 
the  heat  of  summer.  Its  favorite  spot  of  appearance 
is  the  chest,  but  it  may  affect  the  whole  body.  It  is 
slightly  contagious,  sometimes  occurring  as  an  epi 
demic,  and  is  distinguished  by  an  eruption  somewhat 
resembling  measles.  It  consists  in  an  efflorescence 
of  red  patches.,  coalescing,  and  accompanied  by  a  tem- 
perature varying  from  102  to  104  degrees  F.  As  in 
measles,  the  temperature  falls  with  the  appearance  of 


SKIN    DISEASES.  199 

the  eruption.  It  lacks  the  catarrhal  symptoms  of 
measles  and  the  strawberry  tongue  of  scarlet  fever. 
After  three  or  four  days  the  eruption  subsides  and 
there  is  sometimes  slight  desquamation.  Little  treat- 
ment is  demanded  beyond  attention  to  diet  and  cloth- 
ing. 

Remedies  are  aconite^  belladonna^  Pulsatilla. 

URTICARIA.  —  (Syn.  Nettles— Rash— Hives.  )— 
Urticaria  constitutes,  according  to  Kippax,  about  ten 
per  cent  of  all  skin  affections.  Persons  having  idio- 
syncrasies to  certain  articles  of  diet  are  especially 
liable  to  this  disorder,  and  attacks  are  evidenced  by 
the  appearance  of  the  wheal.  The  wheal  varies  in 
size  from  a  millet  seed  to  a  silver  half  dollar,  is  a  hard, 
smooth,  flat  elevation  of  the  skin,  white  or  pink  in 
color.  They  are  of  various  forms,  discrete,  and  oc- 
cur all  over  the  body.  They  provoke  much  itching 
and  burning,  and  usually  subside  after  a  few  hours 
or  days,  but  may  persist  for  many  years.  Usually 
the  wheal  is  evanescent,  comes  in  drops,  and  in  most 
cases  lasts  but  for  a  moment,  at  most  a  day.  In  the 
chronic  form  it  lasts  for  months  and  even  years,  and 
exhibits  several  varieties.  According  to  Jackson, 
urticaria  is  due  to  a  vaso-motor  disturbance.  Serous 
exudation  follows  a  dilatation  of  the  cutaneous  ves- 
sels, and  forms  the  w^heal.  This  is  at  first  pink  and 
then  white,  with  a  pinkish  areola.  The  wheal  is 
pathognomonic  of  urticaria,  and  occurs  only  in  this 
affection.     No  trace  is  left  when  the  eruption  vanishes. 

Treatment  must  begin  with  the  correction  of  all 
errors  in  diet  and  the  removal  of  all  exciting  causes. 
Remedies  useful  are  antinionium  cruduni,  chloral  hy- 


200  PRESENT    STATUS    OF    PEDIATRICS. 

drate,  apis  viellifica^  arsenicum^  ledu?n,  mezereum, 
urtica,  rlius  toxicodendron^  sepia,  oxid  Pulsatilla. 

VESICUL^.  — A  vesicle  is  a  slight  elevation  of  the 
epidermis  containing  a  fluid  usually  clear,  though 
sometimes  opaque.  They  are  most  frequently  glob- 
ular in  form  and  vary  in  size  from  a  pin  head  to  a 
split  pea.  Three  principal  types  of  this  affection  oc- 
cur :  sudamina,  eczema,  and  herpes. 

Sudamina  is  a  disorder  affecting  children  during 
the  heated  term.  It  is  occasioned  by  excessive  sweat- 
ing. Probably  the  mouths  of  the  sweat  ducts  become 
obstructed,  the  epithelial  coat  of  the  skin  is  lifted, 
and  a  clear  pearly  limpid  liquid  appears  in  minute 
drops  beneath.  It  is  not  properly  a  disease  per  se, 
but  results  from  excessive  heat  and  debility.  The 
indications  are  prophylactic.  Remove  excessive  cloth- 
ing and  give  careful  attention  to  the  diet. 

Eczema  is  anon-contagious,  inflammatory,  cutane- 
ous disease,  and  constitutes  one  of  the  most  persist- 
ent and  distressing  affections  of  childhood.  It  is 
either  acute  or  chronic,  more  frequently  the  latter. 
It  may  first  appear  as  an  erythema,  vesicle,  papule, 
or  pustule,  and  becoming  confluent,  exude  a  clear, 
sticky,  honey-like  serum,  which  dries  into  crusts  and 
scales.  These  exfoliate,  and  leave  a  reddened  sur- 
face, from  which  the  exudate  speedily  reproduces  the 
scales.  The  different  forms  of  eczema  are  named 
according  to  the  forms  of  the  eruption  and  its  loca- 
tion: E.  simplex,  E.  rubrum,  E.  pustulosum,  E. 
squamosum,  E.  impetigo.  According  to  Jackson,  the 
following  symptoms  are  characteristic  of  all  forms  of 
eczema,  and  a  majority  of  them  will  be  present  in 


SKIN    DISEASES.  20I 

every  case,  viz. ,  redness,  itching,  inflammation,  moist- 
ure, crusting,  and  cracking.  The  disease  usually 
begins  with  noticeable  systemic  disturbance.  The 
patient  observes  an  itching  or  burning;  examination 
reveals  the  hyperaemia  with  papule,  vesicle,  or  pus- 
tule, or  moisture  of  the  surface. 

This  affection  usually  forms  patches,  which  shade 
off  into  the  healthy  tissue.  The  patches  may  be 
small,  or  nearly  the  whole  surface  may  be  involved. 
From  a  point,  the  affection  spreads  with  more  or  less 
rapidity,  remaining  a  few  days,  or  developing  into  the 
chronic  form.  The  disease  is  especially  liable  to  af- 
fect children.  Out  of  5,000  cases  tabulated  by  White 
in  hospital  practice,  the  ratio  under  ten  years  of  age 
is  as  follows: 

Within  the  first  year  of  hfe 569 

Within  one  and  two  years  of  age 286 

Between  two  and  three  years  of  age 280 

Between  three  and  four  years  of  age 198 

Between  four  and  five  years  of  age 144 

Between  five  and  six  years  of  age 118 

Between  six  and  seven  years  of  age 93 

Between  seven  and  eight  years  of  age 76 

Between  eight  and  nine  years  of  age 66 

Between  nine  and  ten  years  of  age 60 

According  to  Jackson,  it  constitutes  about  one-third 
of  all  skin  diseases.  The  causes  are  depraved  condi- 
tions, constitutional  dyscrasiae,  irritation  of  the  trophic 
nerves,  filth,  dentition,  unsuitable  food,  clothing,  etc. 
Acute  eczema  usually  shows  itself  upon  the  face 
and  hands.  When  the  disease  is  acute,  it  usually  ter- 
minates within  a  fortnight,  or  it  may  become  chronic, 
and  continue  with   varying  degrees  of  intensity  for 


202  PRESENT    STATUS    OF    PEDIATRICS. 

years.  Children  are  peculiarly  liable  to  this  affection, 
because  of  the  numerous  predisposing  and  exciting 
causes  to  which  they  are  subject. 

Of  the  various  forms,  E.  capitas  is  a  variety  most 
frequently  affecting  children,  and  warrants  especial 
mention.  It  occurs  on  the  scalp,  and  is  of  the  form 
designated  rubrum  or  impetiginosum.  It  is  liable  to 
creep  down  upon  the  forehead  and  about  the  ears.  It 
is  at  first  vesicular ;  the  vesicles  rupture,  and  a  thick, 
viscid  fluid  exudes,  forming  with  the  natural  secre* 
tions  of  the  skin  a  thick,  yellowish,  honey-like  fluid. 
It  early  passes  into  the  pustular  form,  the  exudate 
mingling  with  the  dust  and  hair  of  the  head  forms  a 
dense  matted  crust,  which  may  persist  for  years  when 
wanting  proper  care  and  treatment.  Bearing  in  mind 
the  symptoms  as  enumerated  by  Jackson,  the  diagno- 
sis is  as  a  rule  quite  easily  made.  Other  diseases  may 
be  co-incident  with  eczema,  and  will  need  to  be  differ- 
entiated. 

Prognosis. —  In  acute  eczema  an  early  recovery  can 
be  safely  promised.  The  chronic  form  may  persist 
for  years  in  spite  of  the  best  treatment.  In  this  form 
it  is  very  intractable. 

Treatment. — In  its  treatment,  cleanliness  is  of 
prime  importance.  Olive  oil,  vaseline,  etc.,  may  be 
used  to  soften  the  crusts  and  facilitate  their  removal. 
Great  care  must  be  exercised  to  prevent  injury  to  the 
abraded  surface.  Astringent  ointments  are  of  doubt- 
ful utility  and  their  use  is  attended  with  some  danger. 
The  following  remedies  will  be  found  of  advantage : 
Arsenic,  amnioniiini  carbojiicum,  calcarea  carbonica, 
antimoniiivi    crudiini,    clematis    erecta,     dulcaviara. 


SKIN    DISEASES.  203 

graphites,  hepar  sulphuris,  lycopodiiim,  merairius^ 
mezereiivi,  natruni  muriaticum,  petroleum,  psorinuni, 
rhus  toxicodeiidon,  stapJiysagria,  skookiim  chuck,  sul- 
phur, tar  tarns  emcticus,  thuja,  viola  tricolor. 

Herpes  is  an  acute,  non-contagious,  inflammatory 
cutaneous  disease.  It  is  distinguished  by  the  appear- 
ance of  one  or  more  clusters  of  discrete  vesicles  upon 
an  inflamed  base.  Some  types  of  this  affection  are 
incident  to  childhood.  It  may  occur  alone,  or  it  may 
be  co-incident  with  other  diseases.  The  vesicles  ap- 
pear singly  or  in  clusters,  and  usually  dry  up,  leaving 
a  slightly  reddened  surface.  After  the  crust  is  exfo- 
liated, the  reddened  surface  beneath  soon  becomes 
normal.  The  onset  of  the  disease  is  usually  mild,  or 
may  be  preceded  by  fugitive  neuralgic  pains.  In 
herpes  zoster  the  most  frequent  site  of  the  eruption  is 
along  the  course  of  a  nerve  trunk,  either  on  the  body 
or  face.  In  the  former  position  it  is  usually  semi- 
lateral,  reaching  half  way  around  the  body.  Its  symp- 
toms are  neuralgic  pains,  smarting,  and  tingling. 
The  view  generally  held  by  dermatologists  is  that 
herpes  zoster  is  due  to  an  inflammation  of  the  sympa- 
thetic fibers  of  the  ganglia,  through  which  the  nerve 
trunk  passes.  In  childhood  it  always  occurs  in  mild 
form.  Suspicion  as  to  its  being  contagious  is  some- 
times provoked  by  the  occurrence  of  numbers  of  cases 
in  schools  and  crowded  tenements. 

Remedies  to  be  consulted:  Arsenic,  rhus  toxico- 
dendron, bryonia,  cantJiaris,  phosphorus,  magnesia 
pJiosphorica,  mercurius,  and  mezereum. 

ECTHYMA  is  distinguished  by  large,  discrete,  pain- 
ful pustules,  situated  on  an  inflamed  base,  covered 


204  PRESENT    STATUS    OF    PEDIATRICS. 

with  thick  brown  crusts.  When  these  are  exfoliated, 
they  leave  temporary  scars.  The  pustules  are  round 
or  oval  and  of  a  yellowish  cast,  the  surrounding  tis- 
sues being  reddened,  swollen,  and  gradually  fading 
into  healthy  tissue.  The  purulent  contents  soon  dry 
into  heavy  brown  scales  over  an  excoriated  surface. 
This  disease  occurs  in  scrofula  and  cachectic  children 
chiefly  on  the  neck,  shoulders,  and  extremities.  It  is 
distinguished  by  the  pain,  the  brownish  crust,  and  the 
shallow  ulcer.  Unless  it  becomes  chronic,  the  dis- 
ease nms  its  course  in  from  twelve  to  twenty  days. 

Chronic  ecthyma,  which  is  the  more  common 
form,  is  simply  a  persistence  of  the  acute  symptoms, 
and  is  usually  caused  from  some  external  irritation  of 
the  skin.  Foul  air,  filth,  improper  food,  and  deple^ 
tion  from  any  cause  tend  to  provoke  the  disease. 

Remedies  useful:  Ai'senu\  kali  carboniciiin^  viercti- 
rius^  rJius  toxicodendron^  antimoniuvi  criiduvi^  anti- 
vuviiiun  tartariciini,  and  croton  tigliitm. 

IMPETIGO  is  an  acute,  eruptive,  contagious  disease. 
It  is  characterized  by  a  few  or  numerous  closely  ag- 
minated  discrete  vesico-pustules  in  size  from  a  split 
pea  to  a  hazel  nut.  The  exudation  from  these  dries 
and  forms  a  thick,  yellowish-brown  moist  scab,  which, 
according  to  Kippax,  have  the  appearance  of  being 
stuck  on.  The  prodomal  stage  is  brief,  showing  fever 
and  malaise,  shortly  followed  by  the  eruption.  The 
tubercles  primarily  are  small,  increasing  in  size  and 
merging,  after  three  or  four  days,  into  pustules,  sur- 
rounded by  a  reddened  areola.  A  milder  form  of 
this  disease,  impetigo  simplex,  running  about  the 
same  course,  and  characterized  by  nearly  the  same 


SKIN    DISEASES.  205 

symptoms,  is  described  by  some  authors.  It  differs 
from  impetigo  contagioso  in  that  it  is  not  contagious, 
and  the  symptoms  are  generally  milder,  and  the  dis- 
ease yields  more  readily  to  treatment. 

Remedies  are  antimoniuni  criidiiui^  kali  bicJironii- 
ciun,  calcarca  carbonica^  croton  tigliuiii,  eiipJiorbiinn^ 
stapJiysagria^  viola  tricolor^  and  tJuija. 

PRURIGO  is  a  rare,  chronic,  cutaneous  affection. 
It  is  distinguished  by  small,  hard,  whitish  papules 
about  the  size  of  a  pin's  head  and  is  attended  with 
constant  itching.  It  occurs  in  childhood  and  simu- 
lates papular  eczema.  When  the  surface  of  the  pap- 
ules is  broken  by  vigorous  scratching,  a  bloody  serum 
exudes,  which  dries  in  brownish  scales.  The  papules 
are  better  detected  by  touch  than  by  sight,  and  are 
usually  located  on  the  outer  surfaces  of  the  limbs, 
though  all  parts  of  the  body  may  be  affected.  The 
constant  scratching  produces  much  irritation  of  the 
skin,  making  it  rough,  cracked,  and  thickened.  The 
inception  of  the  disease  is  mild,  but  becomes  more 
severe  until  it  is  a  constant  annoyance  to  the  patient. 
As  a  seq-uel  to  the  chafing  produced  by  this  eruption, 
urticaria  and  eczema  sometimes  follow.  The  disease 
usually  results  from  lack  of  cleanliness  and  nerve  ir- 
ritation from  animal  parasites.  In  acute  cases  oc- 
curring in  children  the  prognosis  is  hopeful. 

The  treatment  consists  in  perfect  cleanliness  and 
a  nutritious  diet.  Kippax  recommends  tar  and  sul- 
phur baths.  The  tar  soap  is  useful  in  bathing,  and 
lotions  of  mezereiim  are  recommended  by  Dickinson. 

Remedies  most  useful :  Arsenic^  dolichos pruriens, 
carbolic  acid^  rnerciirius^  lycopodium^  sepia,  hepar  sul- 
phuris^  petroleum. 


206  PRESENT    STATUS    OF    PEDIATRICS. 

PSORIASIS  is  a  chronic,  inflammatory  cutaneous 
disease  appearing  at  any  period  of  life.  It  exhibits 
slightly  raised  patches  varying  from  a  point  to  the  size 
of  a  silver  half  dollar,  and  covered  with  silvery,  white, 
dry  scales.  It  appears  usually  on  the  elbows  and 
knees,  and  constitutes  about  four  and  one-half  per 
cent  of  skin  affections.  The  most  diverse  views  ob- 
tain regarding  the  etiology  of  psoriasis.  Fox  says  he 
is  "constrained  to  believe  that  the  disease  consists 
primarily  and  essentially  in  a  misbehavior  of  the  cell 
elements  themselves,  a  perversion  of  the  ordinary  cell 
life  of  the  epidermis."  Jackson  argues  that  the  dis- 
ease is  a  vaso-motor  neurosis,  and  that  the  careful 
study  of  cases  reveals  antecedent  nervous  disorders. 
Several  different  varieties  are  described  in  form  and 
location ;  the  eruption  is  attended  with  itching,  and 
when  the  scales  are  removed  the  surface  beneath  is 
reddened  and  slightly  elevated.  Owing  to  its  loca- 
tion, flexion  and  extension  of  the  limbs  is  sometimes 
difficult  ^nd  painful,  because  of  the  stiffness  of  the 
skin. 

Treatment. — Fisher  recommends  tar  as  the  best 
of  all  external  applications.  Different  oleates  are 
also  suggested. 

Remedies. — Arsenic^  sepia,  phosphorus,  thuja,  mer- 
ciirius,  pJiytolacca,  and  silicea. 

N.ffiVUS. — Two  varieties  of  this  disease  obtain,  viz. , 
the  vascular  and  pigmentary  naevus.  Naevi,  usually 
congenital,  are  pathological  changes  in  the  skin,  vary- 
ing in  color  from  white  or  pinkish  to  livid.  Nsevus 
vascularis  is  a  discoloration  of  the  skin,  irregular  in  size 
and  contour,  smooth  or  slightly  elevated,  and  is  due 


SKIN    DISEASES.  207 

to  a  multiplication  of  the  vessels  in  the  subcutaneous 
cellular  tissue.  The  pigmentary  nsevus,  or  mole,  is 
due  to  the  excessive  deposit  of  pigment,  or  in  con- 
junction with  the  multiplication  of  connective  tissue. 
Often  a  growth  of  stiff  firm  hairs  appear  on  the  sur- 
face. They  are  frequently  located  on  the  neck,  face, 
and  back.     Both  varieties  are  usually  permanent. 

Treatment. — The  safe  and  speedy  method  of  elec- 
trolysis.    Treatment  with  caustics  is  often  effective. 

Remedies. — Calcarca  carbomca^  cai'bo  vcgetabilis^ 
condurango^  and  tJiiija. 

LENTIGO. — (Syn.  Freckles,  Ephelides.  ) — Lentigo 
is-  characterized  by  small  light  or  dark  brown  spots 
the  size  of  a  mustard  seed  or  a  split  pea,  due  to  the 
deposit  of  pigment  in  the  rete-mucosum,  and  occurs 
chiefly  on  the  exposed  parts  of  the  body.  They  may 
occur  elsewhere  and  are  usually  discrete.  They  ap- 
pear from  the  third  to  the  sixth  year,  affect  both 
sexes,  but  especially  persons  with  fair  skin  and  red 
hair,  and  usually  continue  for  many  years.  They  fade 
with  the  approach  of  mature  and  old  age.  The  pa- 
thology is  obscure.  Shoemaker  believes  it  the  result 
of  slight  peripheral  nervous  disturbance. 

Treatment  consists  in  stimulating  local  applica- 
tions. An  ointment  composed  of  ten  grains  of  oleate 
of  copper  to  an  ounce  of  lanoline  is  recommended. 
Iodine  and  acetic  acid  applied  locally  may  be  'aseful. 

Remedies  Sive  calcarca  carbonica^  sepia,  lycopodium, 
and  sulphur. 

LEUCODERMA  is  characterized  by  the  disappear- 
ance of  the  ordinary  pigment  from  the  skin  in  patches 
varying  in  size  from  a  mere  point  to  large  spots.     Its 


2o8  PRESENT    STATUS    OF    PEDIATRICS. 

usual  site  is  on  the  exposed  parts  of  the  body  and 
more  frequently  on  the  dark  races  than  on  the  white. 
It  is  the  antitype  of  lentigo  and  is  usually  permanent. 
No  remedies  are  known  to  be  useful. 

ACNE  is  an  inflammatory  affection  of  the  sebaceous 
glands.  It  is  usually  chronic  and  appears  in  the  form 
of  papules,  pustules,  or  tuberculosis,  single  or  multi- 
ple, and  affects  usually  the  face,  neck,  and  back. 
They  vary  in  size  from  a  mustard  seed  to  a  pea.  The 
papules  or  pustules  may  be  few  in  number,  or  these 
localities  may  be  profusely  dotted  with  them.  In 
scrofulous  subjects,  when  the  pustular  form  obtains, 
the  face  and  neck  may  be  much  disfigured  by  them, 
except  as  a  result  of  drugging  with  the  salts  of  bro- 
mide and  iodine^  acne  is  not  very  frequently  seen  in 
children.  The  two  forms  of  this  affection  are  acne 
papulosa  and  acne  pustulosa.  All  others  are  but 
modifications  of  these  two  types.  The  disease  is  most 
likely  to  occur  about  the  age  of  puberty,  and  yields 
with  great  difficulty  to  treatment.  Because  of  its 
general  prevalence  at  this  critical  pertod  many  authors 
are  inclined  to  attribute  it  to  some  derangement  of 
the  generative  organs.  It  often  occurs  from  digestive 
disturbance  and  from  reflex  irritation  of  the  other  or- 
gans. 

Treatment. — Both  local  and  constitutional  treat- 
ment are  required.  The  diet  should  be  light  and 
nourishing,  avoiding  all  indigestible  substances  and 
rich  condiments.  The  contents  of  the  papules  and 
pustules  should  be  evacuated  and  frequent  topical  ap- 
plications of  hot  water  recommended.  Various  lo- 
tions are  recommended,  but  are  of  doubtful  utility. 


SKIN    DISEASES.  209 

Vapor  baths  may  be  useful  and  tar  soap  has  proved 
helpful. 

LUPUS  is  a  chronic  cutaneous  disease  sometimes 
affecting  children.  As  defined  by  Dickinson,  it  is  a 
cellular  inflammation  of  the  cutis,  not  forming  new 
tissue,  but  tending  to  a  contraction  or  ulceration  of 
the  skin,  through  fatty  degeneration  and  molecular 
destruction.  Two  varieties  are  named:  Lupus  vul- 
garis and  lupus  erythematosus.  Lupus  first  appears 
as  one  or  more  reddish  or  brown  spots  of  variable 
form  and  size  and  covered  with  thin,  persistent 
scales.  The  initial  lesions  may  vary  in  size  from  a 
mustard  seed  to  a  pea.  When  these  are  situated 
closely  together  as  they  increase  they  coalesce,  form- 
ing patches  of  variable  size  and  shape.  In  the  tu- 
bercular variety  ulceration  of  greater  or  less  extent 
and  depth  occurs  and  sometimes  terminates  in  malig- 
nant formations.  While  rarely  fatal,  lupus  is  a  very 
persistent  disease  and  not  readily  amenable  to  treat- 
ment. 

Remedies. — The  use  of  tuber culine  by  hypoder- 
mic injection  has  been  attended  in  a  few  instances 
with  the  happiest  results.  Dickinson  has  successfully 
used  Jiydrocotyle  asiatica.  Other  remedies  are  ar- 
senic^ thuja,  mirum,  calcarea  carbonica,  and  Jiydrastis. 
Caustic  applications  are  of  but  little  advantage. 

MOLLUSCUM  is  a  disease  of  the  epithelial  layer  of 
the  skin,  distinguished  by  the  development  of  one  or 
more  wart- like,  rounded,  soft,  pinkish  elevations 
from  the  size  of  a  pin's  head  to  a  hazel  nut.  They 
are  usually  prominent,  sessile  or  pedunculated,  and 
exhibit  a  slight  depression  in  the  center.     The  orifice 

15 


2  10  PRESENT    STATUS    OF    PEDIATRICS. 

of  the  gland  duct  opens  in  this  depression,  from 
which,  by  pressure,  may  be  expressed  a  whitish, 
cheesy,  sebaceous  matter.  It  is  slightly  contagious. 
The  etiology  is  obscure. 

Mollusca  fibrosum  is  a  connective  tissue  growth 
in  the  skin  and  may  attain  a  large  size.  They  are 
usually  multiple  and  occur  on  any  part  of  the  body. 

Treatment. — The  tumor  may  be  incised  and  con- 
tents expressed.  The  application  of  a  caustic  to 
their  bases  is  usually  vsufficient  to  destroy  them.  The 
electric  cautery  is  probably  the  most  effective  method. 

Remedies  indicated  are  silicca,  thuja,  tencriuni^ 
sulphur,  and  arsenic. 

VERRUCA. — Warts  are  hypertrophied  i^apillde  of 
the  skin  and  vary  in  size  from  a  mustard  seed  to  a 
split  pea.  They  are  conical,  hard  and  sessile,  some- 
times nodulated  or  may  be  cleft.  They  usually  ap- 
pear in  groups  and  their  favorite  location  is  the  neck, 
face,  and  hands.  They  are  particularly  liable  to  oc- 
cur in  childhood,  have  no  effect  upon  the  general 
health  and  their  etiolog}^  is  obscure.  They  appear 
and  disappear  spontaneously  and  are  painless. 

Treatment. — In  the  writer's  hands,  tJiuja  has  been 
the  most  effective  remedy.  The  cautery  and  nitric 
acid  will  sometimes  remove  them. 

SCABIES  is  a  contagious,  parasitic,  cutaneous  dis- 
ease. It  is  caused  by  the  minute  parasite,  acarus 
scabei,  burrowing  in  the  skin,  its  presence  being  evi- 
denced by  papules,  vesicles,  and  pustules,  and  is  ac- 
companied by  intense  itching.  The  severe  irritation 
is  produced  by  the  female  parasite  as  it  burrows,  mak- 
ing tortuous  canals  in  the  integument,  in  which  it 


SKIN    DISEASES.  211 

deposits  from  ten  to  fifty  ova.  The  itching  from 
scabies  is  always  worse  at  night  and  in  persons  with 
dehcate  skin.  The  site  which  is  usually  infested  is 
between  the  fingers  and  about  the  wrists,  on  the 
breasts  and  the  abdomen,  and  the  internal  part  of  the 
thighs.  In  children  the  inflammation  produced  by 
the  parasite  and  the  severe  scratching  not  infrequently 
induces  excoriated  lesions  and  eczematous  patches. 
The  disease  shows  no  tendency  to  a  spontaneous  cure. 
It  is  essentially  chronic.  Within  a  fortnight  from  the 
invasion  of  the  disease  the  characteristic  marks  and 
the  itching  may  appear  on  all  parts  of  the  body.  The 
diagnosis  is  easily  made  and  the  cure  of  the  affection 
is  not  difficult. 

Treatment. — After  giving  the  child  a  thorough 
bath  with  soap  and  water  at  bedtime,  anoint  the  body 
with  a  sulpliur  ointment  and  in  the  morning  remove 
the  same  by  another  bathing.  This  process  must  be 
repeated  every  third  evening  for  a  fortnight.  Many 
ointments  and  lotions  besides  the  above  are  recom- 
mended for  the  cure  of  scabies,  but  none  has  proved 
so  effective  in  the  hands  of  the  writer.  The  internal 
administration  of  sulphur  in  potency  is  recommended. 

SYPHILODERMA.— Syphilis,  as  it  affects  the  skin 
in  children,  may  be  either  hereditary  or  acquired.  It 
is  the  product  of  a  specific  poison,  the  initial  lesion 
of  which  is  the  chancre.  These  are  simply  the  ordi- 
nary manifestations  of  secondary  and  tertiary  syph- 
ilis on  the  skin.  When  this  fact  is  once  definitely  de- 
termined, a  vantage  point  of  great  importance  is 
gained. 

The  er3^thematous  form,  according  to  Atkinson,  be- 


2  12  PRESENT    STATUS    OF    PEDIATRICS. 

gins  as  discoid  or  oval  spots  about  the  size  of  the  fin- 
ger nail,  and  is  of  a  pale  red  color,  fading  on  press- 
ure. They  sometimes  coalesce  over  large  areas  and 
appear  on  the  abdomen,  neck,  and  face.  After  three 
or  four  days  the  color  changes  to  a  dull  yellow,  and 
remains  for  several  weeks,  gradually  fading  without 
pigmentation.  When  the  palm,  soles,  and  firmer 
portions  of  the  integument  are  affected,  a  thin  des- 
quamation occurs.  In  this  form  soreness  of  the  throat 
sometimes  obtains,  and  alopecia  is  not  infrequent. 
Both  the  miliary  and  the  lenticular  form  of  papules 
occur  in  this  type.  They  are  usually  pale  red,  and 
shortly  change  to  the  coppery  hue  indicative  of  syph- 
ilitic eruptions.  Papules  are  usually  discrete,  are 
widely  scattered,  and  are  devoid  of  sensation.  Both 
forms  are  chronic  in  character  and  manifest  a  marked 
tendency  to  recur. 

The  vesicular  is  a  rare  form  and  usually  develops 
into  the  pustular  variety. 

The  pustular  form  is  indicative  of  the  tertiary  stage. 
They  may  begin  as  papules  or  vesicles,  quickly 
changing  into  pustules,  and  may  be  acuminated  or 
flat  and  are  of  various  sizes.  The  purulent  contents 
dry  into  heavy  brownish  crusts  over  an  ulcer  of 
greater  or  less  depths.  When  these  crusts  are  exfo- 
liated the  ulcer  heals  by  granulation. 

The  tubercular  syphiloderm  is  a  firm,  oval,  nodular, 
smooth,  reddish-brown  mass  in  the  skin,  and  is  inci- 
dent to  the  tertiary  period.  They  appear  on  the  face 
and  neck,  but  may  occur  on  any  part  of  the  body. 
Their  growth  is  slow  and  after  a  few  months  they 
disappear  by  resolution  or  ulceration.      The  bullous 


SKIN    DISEASES.  213 

eruption  evidences  the  profound  inherited  syphilitic 
poison  in  very  young  infants.  These  develop  within 
the  first  few  weeks  or  days,  and  consist  of  blebs 
varying  in  size  from  a  pea  to  a  walnut.  They  contain 
a  serous  or  sero-purulent  fluid  and  are  surrounded  by 
a  brownish  areola.  Their  favorite  location  is,  accord- 
ing to  some  authors,  the  soles  of  the  feet  and  the 
palms  of  the  hands.  According  to  others,  they  may 
locate  upon  the  trunk  or  limbs.  In  a  fatal  case,  re- 
cently treated  by  the  writer,  they  appeared  upon  all 
parts  of  the  body.  Thick,  greenish  crusts  form  over 
the  site  of  the  lesions.     Recovery  is  the  exception. 

The  remedies  indicated  are  those  most  useful  in 
the  syphilitic  dyscrasia.  Among  these  are  arsenic^ 
kali.,  iodiiini^  merciirius^  kreosotiim^  mccercuiii^  nitric 
acid^  tJiiija^  sulphur^  staphysagria,  SiVid.  Phytolacca. 

TINEA  FAVOSA  is  the  most  intractable  of  the  vege- 
table parasitic  diseases.  It  is  contagious  and  is  dis- 
tinguished by  the  presence  of  pale  yellow,  depressed, 
brittle  crusts.  The  hair  follicle  seems  to  afford  a 
nidus  for  the  germ  and  the  crusts  are  usually  pierced 
by  a  hair.  The  hair  becomes  brittle  and  breaks  off, 
or  is  even  destroyed.  The  favorite  location  is  upon 
the  scalp,  but  no  part  of  the  body  is  exempt  from  the 
attack.  The  initial  lesion  is  a  small  red  patch  of 
cuticle  with  slight  itching  and  burning,  shortly  fol- 
lowed by  an  eruption  of  small  vesicles.  As  the 
germs  multiply  the  vesicles  coalesce,  shortly  assum- 
ing a  tawny  yellow  color,  and  become  depressed  be- 
neath the  surrounding  level.  These  crusts  are  quite 
adherent  over  considerable  areas,  and  the  skin  beneath 
is  smooth  and  shining.     According  to  Kippax,  it  pre- 


2  14  PRESENT    STATUS    OF    PEDIATRICS, 

sents  under  the  microscope  a  field  studded  mostly 
with  oval  conidia,  varied  as  to  size,  and  mycelia 
of  different  lengths,  and  more  or  less  filled  with 
granules.  The  sulphur-yellow  crust  and  the  peculiar 
mouse-like  odor  are  aids  in  diagnosis.  The  firm 
crusts  pulverize  beneath  the  fingers,  or  after  a  few 
weeks  change  to  a  greenish  or  dirty-yellow  color. 
The  brittle  hair  breaks  off,  is  dry  and  easily  pulled 
out  by  the  roots,  and  is  not  likely  to  be  reproduced  on 
account  of  injury  to  hair  follicles  by  the  germ. 

Treatment. — Cures  are  effected  by  the  use  of  inter- 
nal remedies  and  local  applications  of  parasiticides. 
Of  the  latter.  Shoemaker  recommends  boro-glyceride^ 
to  be  followed  by  preferably  the  vierciirials  a  few 
hours  later.  Siclphur  ointment  is  one  effective  agent. 
Many  others  are  effective  if  persistently  used.  Rem- 
edies useful  are  agariciis^  arsenic^  baryta  carbonica^ 
dulcamara,  graphites,  lycopoditun,  mezeretun,  sulphur, 
viola  tricolor. 

TINEA  TONSURANS,  or  ring'-worm,  is  a  vege- 
table parasitic  disease  of  the  skin  due  to  the  trycoph- 
yton.  When  affecting  the  scalp,  it  is  evidenced  by 
itching  and  redness  of  the  affected  part.  The  hair 
becomes  lusterless,  lifeless,  brittle,  and  falls  out.  The 
scalp,  especially  in  children  of  the  lymphatic  tempera- 
ment, is  dotted  more  or  less  thickly  with  thin  cursts. 
In  aggravated  form,  vesicles  or  even  pustules  obtain, 
and  because  of  the  irritation  excited  may  simulate 
an  eczema.  A  single  patch  of  the  vesicles  may  ap- 
pear, or  the  scalp  maybe  dotted  with  groups  of  them. 
It  is  more  readily  detected  and  studied  when  appear- 
ing on    the  hairless  portions  of  the  body,  especially 


SKIN    DISEASES.  215 

the  neck  and  face,  for  which  it  seems  to  have  an  af- 
finity. First,  small  groups  of  minute  vesicles  ap- 
pear on  a  circumscribed,  inflamed  base,  accompanied 
by  itching  and  burning.  New  vesicles  continue  to 
appear  about  the  margin  of  the  original  patch,  which 
quickly  dries  and  is  covered  with  minute  scales.  As 
it  heals  in .  the  middle,  the  newly  formed  vesicles  on 
the  margin  contin^^e  to  encroach  upon  the  healthy 
tissue.  This  form  of  growth  gives  it  the  popular 
name  of  ring-worm.  The  patches  may  become  as 
large  or  larger  than  a  silver  dollar. 

Treatment. — The  cure  of  this  form  of  tinea  is 
less  difficult.  A  leaf  of  tobacco  the  size  of  the  af- 
fected patch,  moistened,  and  bound  on  it  over  night 
has,  in  the  writer's  hands,  rarely  failed  to  cure.  A 
few  topical  applications  of  acetic  acid  is  usually  ef- 
fective. The  mercurials  are  also  efficient.  Sepia  and 
tellurium  are  all  the  internal  remedies  needed. 


2l6  PRESENT    STATUS    OF    PEDIATRICS. 


CHAPTER  X. 


MINOR  INFECTIOUS  DISEASES. 

BY  MARK  EDGERTON,  M.  D. ,  PROFESSOR  OF  MATERIA  MEDICA,  KANSAS 
CITY  HOMCEOPATHIC  MEDICAL  COLLEGE,  KANSAS   CITY,   MO. 

We  will  consider  under  this  head  measles,  rubella, 
varicella,  whooping-cough,  and  mumps. 

MEASLES,  RUBEOLA,  OR  MORBILLL— Measles 

is  an  acute  epidemic  contagious  disease,  characterized 
by  a  peculiar  papular  eruption  occurring  usually  on 
the  fourth  day  of  the  attack,  preceded  by  catarrhal 
symptoms 'and  followed  by  slight  desquamation. 

Contag'ion. — The  contagious  principle  exists  in  the 
breath,  the  exhalations  from  the  skin,  the  blood,  the 
tears,  the  nasal  and  bronchial  secretions,  and  the 
urine  and  faecal  discharges.  Infection  takes  place  in 
the  majority  of  cases  through  the  mucous  membrane 
of  the  respiratory  tract,  the  inspired  air  carrying  the 
active  contagious  principle.  It  affects  both  sexes 
alike  and  equally. 

Susceptibility. — Infants  under  six  months  are 
generally  exempt.  It  is  a  disease  of  childhood,  but 
adults  who  have  never  had  it  are  susceptible. 

Symptomatolog'y. — The  disease  has  four  stages, 
incubation,  invasion,  eruption,  and  decline. 

Incubation. — The   period   elapsing    between    ex- 


MINOR    INFECTIOUS    DISEASES.  217 

posure  and  the  commencement  of  the  manifest  symp- 
toms varies  from  seven  to  twenty-one  days. 

Invasion. — The  stage  of  invasion  may  be  ushered 
in  abruptly  by  vomiting,  chills,  fever,  headache,  pain 
in  the  back  and  limbs,  and  accompanied  by  catarrhal 
symptoms  of  the  mucous  membranes  of  the  eyes, 
nose,  throat,  larynx,  trachea,  and  bronchial  tubes; 
usually,  however,  the  onset  is  gradual,  and  loss  of 
appetite,  malaise,  and  mild  catarrhal  symptoms  with 
slight  fever  are  first  observed.  Muco-purulent  symp- 
toms with  frequent  sneezing  are  common,  followed 
by  or  accompanied  with  an  annoying  cough.  The 
fever  during  this  stage  ranges  from  102  to  104  de- 
grees. 

Eruption. — About  the  fourth  day  the  eruption 
appears  on  the  forehead,  temples,  and  cheeks,  and 
gradually  extends  to  the  face,  neck,  extremities,  and 
trunk.  The  eruption  at  first  appears  as  minute  red 
spots,  rapidly  increasing  in  number  and  size  and  be- 
coming papular  may  run  together,  forming  crescentic 
spots  upon  the  clear  white  skin.  The  catarrhal  symp- 
toms and  cough  continue  during  this  stage,  which  lasts 
from  five  to  seven  days. 

Decline. — The  eruption  has  faded,  the  fever  sub- 
sides, but  the  catarrhal  symptoms  still  continue  and 
are  the  last  to  disappear.  The  appetite  and  natural 
disposition  of  the  child  return;  and  slight  desquama- 
tion takes  place.  At  times  we  find  cases  of  morbilli 
sine  catarrh,  also  morbilli  sine  exanthemata. 

Black  or  malig'nant  hemorrhagic  measles  are 
characterized  by  rapid,  feeble  pulse,  high  temperature, 
cold  extremities,  patient  is  anxious  and  restless,  or 


2l8  PRESENT    STATUS    OF    PEDIATRICS. 

somnolent  with  a  tendency  to  convulsions  or  coma. 
Death  may  take  place  before  the  rash  is  developed, 
or  there  may  appear  confluent,  dark  liquid  or  black 
papules,  which  fading  leave  dark  yellow  stains.  This 
type  occurs  in  broken-down  subjects  and  those  suffer- 
ing- from  dyscrasiae,  and  is  extremely  fatal. 

Complications. — Measles  may  be  complicated  with 
conjunctivitis,  stomatitis,  cancrum  oris,  diphtheritic 
throat,  bronchitis,  pneumonia,  enteritis,  colitis,  otal- 
gia, or  otitis. 

Prog'nosis  is  favorable  if  previous  health  was  good, 
the  eruption  comes  out  on  time,  there  be  no  untoward 
symptoms  nor  any  dangerous  complications.  One  at- 
tack commonly  protects  against  subsequent  infection, 
but  occasionally  there  will  be  a  second  attack  and  a 
third  is  not  unknown. 

Treatment.  —  The  treatment  is  preventive,  hy- 
gienic, and  therapeutic.  Isolate  the  patient  in  a  large, 
well  ventilated  apartment.  Shade  the  eyes,  but  do 
not  shut  all  light  from  the  room.  Disinfect  all  cloth- 
ing and  patient's  former  apartment,  also  all  discharges. 
Give  patient  plenty  of  cool  water  to  drink.  When  the 
rash  is  tardy  and  temperature  very  high,  a  warm  bath 
and  some  hot  lemonade  will  assist  in  bringing  it  to  the 
surface.  The  room  should  be  kept  at  a  temperature 
of  about  65  to  75  degrees  F.  or  such  other  tempera- 
ture as  the  patient  is  used  to.  The  diet  should  be 
light,  consisting  of  soups,  cereals,  bread,  toast,  milk, 
and,  if  the  bowels  are  not  disordered,  fruits.  When 
the  fever,  catarrhal  irritation,  and  desquamation  have 
passed  off,  a  warm  bath  should  be  taken,  followed 
next  day  by  a  tepid  or  even  cool  bath,  rubbing  briskly 


MINOR    INFECTIOUS    DISEASES.  219 

SO  that  no  cold  is  taken.  After  this,  patient  may  be 
allowed  to  go  ont  if  the  weather  be  favorable. 

VARICELLA,  OR  CHICKEN  POX.— Named  from 
its  resemblance  of  the  vesicles  to  size  of  chick-pea. 
Not  a  disease  of  domestic  fowl. 

The  susceptible  period  is  from  birth  to  five  years, 
but  it  has  been  met  with  in  adult  life.  Chicken-pox 
is  epidemic.  Never  attacks  but  once  during  life. 
Rarely  presents  a  prodromal  stage. 

Symptomatolog'y — It  usually  begins  with  head- 
ache, slight  fever,  gastric  disturbances,  and  prompt 
appearance  of  the  eruption.  Often  the  appearance 
of  individual  vesicles  about  the  roots  of  the  hair  and 
on  the  back  are  the  first  evidences  of  the  oncoming 
of  the  disease,  or  it  may  begin  with  chilliness,  inter- 
mingled with  hot  flashes,  headache,  peevishness, 
thirst,  and  general  unrest  appearing  twenty- four 
hours  before  the  appearance  of  the  vesicles,  the  fever 
ranging  at  this  time  from  99}^  to  104  degrees  F. 
The  eruption  occurs  in  successive  crops,  the  first  ef- 
florescence hardly  attains  its  maximum  until  the  sec- 
ond crop  comes  out,  the  whole  occupying  from  twenty- 
four  to  thirty-six  hours.  The  vesicles  are  most 
numerous  on  the  forehead  and  back,  each  vesicle 
consisting  of  a  body  or  base,  red,  and  looking  like  a 
hypersemic  spot,  varying  in  size  from  a  pin-head  to  a 
split  pea  and  an  apex  or  vesicle  which  appears  later, 
ovoid  in  form,  one  celled,  and  filled  with  clear  lymph, 
which,  as  it  dries,  causes  the  convexity  of  large  pocks 
to  collapse  and  the  apex  to  become  concave,  which 
usually  occurs  a  few  hours  after  its  appearance.  The 
disease  runs  from  one  week  to  twelve  days. 


220  PRESENT    STATUS    OF    PEDIATRICS. 

Diagnosis. — Varicella  may  be  differentiated  from, 
small-pox  by  the  short  invasion  and  slight  or  wanting- 
constitutional  symptoms ;  the  eruption  being  superfi- 
cial and  not  hard,  and  nodular  and  like  shot,  and  it 
presents  its  vesicles  at  once.  The  vesicles  of  chicken- 
pox  are  one  celled,  never  partitioned,  never  confluent, 
and  do  not  aggregate  over  face,  hands,  and  feet,  Um- 
bilication  is  rare,  belongs  only  to  occasional  and  large 
pocks.  The  disease  is  uninfluenced  by  vaccination  or 
previous  attacks  of  small-pox. 

Prog'nosis. — The  prognosis  is  always  favorable,  ex- 
cept when  complicated  with  scarlet  fever,  syphilis, 
tuberculosis,  or  small-pox. 

Treatment. — The  patient  should  receive  nourish- 
ing food  and  plenty  of  fresh  air,  but  no  bathing  dur- 
ing vesicular  stage. 

RUBELLA,  ROTHELN  OR  GERMAN  MEASLES.— 
Rubella  is  a  disease  closely  resembling  measles  at 
times  and  a  mild  form  of  scarlet  fever  in  other  epi- 
demics, but  which  does  not  afford  immunity  from 
either,  nor  is  the  child  immunized  by  a  previous  at- 
tack of  either  of  the  other  diseases.  It  attacks  chil- 
dren of  all  ages  and  adults. 

Susceptibility. — Children  under  five  years  of  age 
are  the  most  susceptible. 

Incubation. — Period  of  incubation  from  one  to 
three  weeks,  but  it  usually  develops  in  about  ten  days 
after  exposure.  It  is  not  fatal  and  there  is  rarely  any 
seqiicllcE  following  it.  It  may  occur  sporadically  as 
well  as  in  epidemic. 

Symptomatolog'y. — It  begins  with  headache,  shiv- 
ering, chilliness  intermingled  with  heat,  some  sore- 


MINOR    INFECTIOUS    DISEASES.  221 

ness  of  the  throat,  aching  of  the  limbs,  and  a  gen- 
eral feeling  of  discomfort.  In  from  twenty-four  to 
thirty-six  hours  an  eruption  will  appear  on  the  face 
and  forehead,  spreading  thence  over  the  trunk  and 
limbs;  or  it  may  appear  without  any  prodromic 
symptoms,  and  may  present  itself  on  the  entire  bodily 
surface  within  a  few  hours  after  appearing  on  the  face. 
The  eruption  is  papular,  smaller  than  measles,  and 
does  not  aggregate  in  crescentic  bodies,  is  bright  red 
in  color  and  not  scarlet.  The  eruption  lasts  from 
five  to  six  days,  but  begins  to  pale  off  after  the  first 
thirty- six  hours.  Desquamation  takes  place  in  bran- 
like scales.  The  throat  is  sore,  of  a  deep  red  color, 
the  tonsils  being  swollen  and  painful  when  swallow- 
ing. These  throat  symptoms  usually  subside  with 
the  fever  and  rash. 

DIFFERENTIAL  DIAGNOSIS.  —  Rubella.  —  The 
rash  is  erythematous,  rough,  papular,  and  appears  on 
the  face  and  forehead.  The  pulse  is  not  rapid,  rarely 
above  no.  The  temperature  rarely  above  102  de- 
grees. Desquamation  is  bran-like  and  the  catarrhal 
symptoms  are  slight. 

Scarlet  Fever.  —  The  rash  is  punctiform,  dif- 
fused, skin  high  colored,  scarlet.  The  rash  begins 
on  the  neck  and  upper  part  of  the  chest.  There  is 
an  absence  of  catarrhal  discharges  from  nose  and 
eyes.  A  white  line  is  seen  about  the  mouth  and 
wings  of  the  nose.  Pulse  is  rapid,  temperature  high, 
and  the  disease  is  generally  ushered  in  with  vomiting. 
Desquamation  is  in  large  scales  and  masses. 

Measles. — Has  more  pronounced  catarrhal  symp- 
toms,  hoarse   cough,   presence   of    the   rash   in   the 


222  PRESENT    STATUS    OF    PEDIATRICS. 

mouth,  and  the  measles  smell.  The  rash  is  more 
general,  confluent,  and  crescentic  in  appearance. 

Caution. — If  the  diagnosis  is  doubtful,  take  all 
'the  precautions  necessary  for  the  more  severe  disease. 

Therapeutics. — For  rubella  the  following  reme- 
dies will  be  most  frequently  indicated :  Aconite,  bella- 
donna, ferriini  pliosphoricuni,  dulcamara,  cantJiaris^ 
apis,  Jiyoscyannis. 

For  varicella  the  remedies  most  often  used  are  aco- 
nite,  belladonna,  and  pidsatilla.  A  very  few  doses  of 
either  one,  according  to  the  symptoms,  will  be  all  that 
is  necessary  in  the  large  majority  of  cases. 

For  rubeola,  aconite,  arsenic,  belladonna,  bryonia^ 
canipliora,  cuprnni,  eupJirasia,  ipecac,  kali  bicJironii- 
cnni,  mercurius,  phosphorus,  Pulsatilla,  rJius  toxicoden- 
dron, sulphur,  veratrtun  viride. 

PAROTITIS,  OR  MUMPS.— A  contagious,  epi- 
demic, inflammation  and  enlargement  of  the  parotid 
glands  on  one  or  both  sides.  Generally  occurring  in 
youth,  acute  in  its  origin  and  course,  accompanied  by 
fever  and  fever  symptoms,  followed  in  some  cases  by 
an  abscess  of  the  gland,  but  usually  subsiding  in  a 
week  or  ten  days  without  leaving  any  trace.  Epi- 
demics are  usually  in  the  spring  or  fall. 

Susceptibility  is  confined  to  the  period  of  child- 
hood and  early  youth,  although  adults  who  have  never 
had  it  are  susceptible.  Males  are  more  susceptible 
than  females.  One  attack  gives  immunity  from 
others. 

Symptomatolog'y. — The  period  of  incubation  is 
from  six  days  to  two  weeks.  Prodromic  symptoms 
are  slight  or  wanting.      The  patient  often  first  expe- 


MINOR    INFECTIOUS    DISEASES.  223 

riences  shooting-  pains  beneath  the  lobe  of  the  ear 
during  motion  of  the  jaw.  A  deep  seated  swelling 
soon  appears,  gradually  increasing  until  the  side  of 
the  face  and  neck  are  implicated,  the  head  being 
usually  inclined  to  this  side.  Later  the  other  side 
will  take  on  a  similar  swelling.  In  many  cases  there 
is  very  little  or  no  inconvenience  from  this  condition; 
in  others,  there  is  excruciating  pain  on  swallowing, 
difficulty  in  enunciating  words,  and  great  salivation, 
ringing  in  the  ears,  with  loss  of  appetite,  vomiting, 
constipation,  etc.  Metastasis  sometimes  takes  place. 
When  it  does,  there  will  be  a  rapid  disappearance  of 
the  swelling,  which  in  boys  is  followed  by  orchitis  of 
the  same  side,  with  scrotal  oedema.  In  girls,  the 
breasts  or  ovaries  may  be  affected  by  this  metastasis. 
This  inflammation  usually  runs  about  the  same  course 
as  mumps,  or  may  subside  and  be  followed  by  an 
exacerbation  of  the  parotid  symptoms.  The  duration 
of  the  disease  is  about  ten  days.  Death  rarely,  if 
ever,  occurs.  Cooling  drinks  and  a  light  nourishing 
diet  are  indicated.  Avoid  wet,  dampness,  violent  ex- 
ercise, or  straining. 

Therapeutics. — The  remedies  most  frequently  in- 
dicated are  belladonna^  mercurius,  rhits^  euphrasia, 
carbo  vegetabilis^  coccuhis.  Metastasis  may  call  for 
arsenic^  aiirmn^  carbo  vcgctabilis,  mix  vomica,  Pulsa- 
tilla, etc. 

PERTUSSIS,  OR  WHOOPING-COUGH.— Symp- 
tomatolog'y. — Whooping-cough  is  a  communicable 
disease  depending  on  a  specific  poison,  prevailing 
epidemically  and  sporadically.  It  is  characterized  by 
fever,  malaise,  irritation  of  the  respiratory  tract,  ca- 


224  PRESENT    STATUS    OF    PEDIATRICS. 

tarrh,  and  subsequently  by  a  hard,  dry,  convulsive, 
paroxysmal  cough.  It  attacks  both  sexes  and  all 
ages,  but  especially  children,  rarely  occurring  more 
than  once.  The  period  of  incubation  varies  from  four 
to  fourteen  days.  It  usually  runs  a  course  varying 
from  three  weeks  to  three  months.  It  is  most  fatal  in 
children  under  three  years  of  age,  in  females,  and  in 
cold  weather. 

Complication. — It  may  be  complicated  with  other 
lesions,  as  ulceration  of  the  fraenum  linguae,  capil- 
lary bronchitis,  emphysema,  hemorrhages,  etc. 

PPOg'nosiS. — Whooping-cough  in  the  first  stage 
appears  like  a  common  cold  or  coryza.  The  second 
stage  is  characterized  by  a  whoop  and  a  paroxysmal 
cough  with  vomiting.  The  third  stage  is  a  stage  of 
decline. 

Treatment. — The  child  should  be  isolated  in  well 
ventilated  apartments,  with  an  even  summer-like 
temperature,  and,  when  the  weather  will  permit, 
should  be  given  an  airing  daily.  Cleanliness,  fresh 
air,  light  and  nourishing  diet  are  absolutely  essential. 
The  apartments  and  clothing  should  be  disinfected 
and  the  ejecta  from  the  nose,  throat,  and  stomach 
should  be  received  into  a  cloth,  which  should  be 
burned,  or  into  water  containing  a  disinfectant. 

Therapeutics. — This  disease  requires  careful  in- 
dividualization in  the  selection  of  the  remedy.  The 
therapeutics  are  too  voluminous  for  a  book  of  this 
character. 


CHOLERA    INFANTUM.  225 


CHAPTER  XI. 


CHOLERA  INFANTUM. 

BY   CHARLES    D.   CRANK,   M.  D. ,   EMERITUS  PROFESSOR  OF  PEDIATRICS, 
PULTE  MEDICAL  COLLEGE,   CINCINNATI,  OHIO. 

Etiology  and  Pathology. — In  the  examination  of 
a  class  of  medical  students,  one  of  the  questions  was, 
"Give  the  etiology  and  differential  diagnosis  of 
cholera  infantum. "  The  reply  was,  "  I  do  not  know 
the  exact  etiology  of  cholera  infantum,  but  I  do  know 
that  it  is  not  summer  complaint,  the  so-termed  scourge 
of  American  cities."  However  incomplete  the  an- 
swer, it  expressed  the  consensus  of  the  medical  opinion 
of  to-day.  The  want  of  uniformity,  both  in  anatomi- 
cal examinations  and  in  the  study  of  conditions,  has 
led  to  diversity  of  opinion  among  writers.  Some 
authorities  pronounce  cholera  infantum  inflammatory 
in  its  nature,  claiming  ihsit  post-mortem  examinations 
evidence  the  "essential  lesion,"  and  that  when  the 
lesion  is  wanting,  the  onset  has  been  so  severe  and 
the  effect  so  disastrous  as  to  produce  death  before 
the  alimentary  tract  had  time  to  undergo  the  essen- 
tial structural  change.  Equally  good  observers  fail 
to  confirm  such  changes,  claiming  that  they  appear 
only  when  the  case  has  passed  beyond  the  acute. 
Rapidity  of  action  is  the  characteristic  and  alarming 
16 


226  TRESENT    STATUS    OF    PEDIATRICS. 

feature  of  cholera  infantum.  It  runs  its  course 
quickly,  and  inflammatory  lesions  may  quickly  super- 
vene, but  such  lesions  are  no  inore  a  part  or  an  "essen- 
tial lesion  "  of  cholera  infantum  than  is  nephritis  of 
scarlet  fever  or  paralysis  of  diphtheria. 

In  any  event,  classification  of  infantile  intestinal 
troubles  does  not  depend  upon  pathological  findings, 
and  practically  is  of  no  service  in  the  treatment. 
Symptomatology  teaches  us  that  cholera  infantum  is 
not  entero-colitis,  neither  is  it  simple  diarrhoea,  and, 
as  compared  with  either,  it  is  a  rare  disease  and  enti- 
tled to  a  distinct  nosological  position. 

In  an  orphan  asylum  in  which  are  confined  never 
less  than  one  hundred  infants  and  children,  during  a 
period  of  eleven  years  there  is  recorded  but  four  cases 
of  cholera  infantum,  while  both  the  inflammatory 
and  simple  forms  of  bowel  troubles  were  not  of  in- 
frequent occurrence.  Extreme  heat  and  the  vitiated 
atmosphere  of  our  crowded  cities  are  supposed  etio- 
logical factors;  but  from  careful  investigation  it 
appears  that  cholera  infantum  does  not  depend  upon 
high  temperature  alone,  for  it  is  not  so  prevalent  in 
southern  latitudes.  The  only  noted  effect  of  tempera- 
ture was  when  it  continued  high  both  day  and  night ; 
and  further,  that  in  proportion  to  population  (with 
children  at  the  breast)  it  was  as  frequent  in  rural  dis- 
tricts as  in  towns  and  cities.  The  influence  of  rain- 
fall and  humidity  was  observed  for  a  number  of  years, 
and  show  that  cholera  infantum  was  more  prevalent 
during  a  dry  than  a  wet  season.  The  fact  that  chol- 
era infantum  is  rarely  encountered  abroad  has  sug- 
gested that  the  frequent  and  sudden  climatic  changes. 


CHOLERA    INFANTUM.  227 

conditions  so  peculiar   to  the   United    States,  are   a 
causative  factor  of  prime  importance. 

The  suddenness  and  violence  of  attack,  followed  so 
quickly  with  well  marked  nervous  phenomena,  sug- 
gests a  "neurosis" — the  exosmosis  of  serum  through 
the  alimentary  mucous  lining  being  due  to  disturbance 
of  the  "  vaso-motor. "  The  undeveloped  nervous  sys- 
tem of  the  infant,  enfeebled  by  teething  and  prolonged 
high  temperature,  disturbs  the  equilibrium,  bringing 
about  a  form  of  vaso-motor  paralysis. 

The  frequency  of  cholera  infantum  during  the 
heated  term,  the  high  body  temperature,  105  degrees 
F.  and  higher,  together  with  the  suddenness  and  vio- 
lence of  attack,  contracted  pupils,  embarrassed  res- 
piration and  suppressed  urine,  establish  a  striking 
similarity  to  sun-stroke,  or  thermal  fever,  but  the 
points  of  dissimilarity  are  sufficient  to  clearly  deter- 
mine a  distinct  diagnosis.  Many  other  theories  have 
been  advanced,  but  no  one  has  been  found  all  suffi- 
cient. The  weight  of  opinion  favors  the  ingestion  of 
poisonous  food,  and  the  presence  of  bacteria.  The 
profession  awaits  the  isolation  of  the  poison  and  the 
germ. 

Nomenclature. — Cholera  infantum,  or  cholera  in 
the  infant,  derives  it  name  from  its  close  resemblance 
to  cholera  in  the  adult,  though  considered  in  all  its 
features  it  is  more  analogous  to  cholera  morbus.  The 
three  choleras,  Asiatic  cholera,  cholera  infantum,  and 
cholera  morbus,  manifest  a  close  resemblance,  and  the 
most  casual  observer  could  not  fail  to  discover  that 
they  are  members  of  the  same  family.  During  an  epi- 
demic of  Asiatic  cholera  it  is  not  possible  to  diagnose 


228  PRESENT    STATUS    OF    PEDIATRICS. 

it  from  cholera  morbus,  and  the  age  alone  warrants 
us  in  pronouncing  similar  manifestations  cholera  in- 
fantum. Johnson  refers  to  the  remarkably  close  simi- 
larity in  the  etiology,  symptoms,  and  pathology  of 
cholera  infantum  and  cholera  morbus.  A  study  of 
the  three  choleras  leaves  but  little  doubt  that  the 
causative  factor  is  the  same  in  all ;  a  micro-organism, 
same  in  nature,  differing  in  degree.  In  Asiatic 
cholera,  it  has  been  acceptably  demonstrated.  Cholera 
infantum  and  cholera  morbus  await  further  research. 

Since  the  reports  of  Escherich,  Bagnisky,  Jeffries, 
and  Booker,  no  new  developments  have  been  made  in 
the  isolation  of  intestinal  bacteria.  We  do  not  kjiozv 
positively  that  any  form  of  infantile  intestinal  troubles 
sustain  a  constant  relation  to  any  variety  of  bacteria, 
but  there  is  a  growing  belief  that  all  are  due  to  toxi- 
cogenic  (poison  producing)  bacteria,  and  while  these 
may  be  true  infectious  diseases  of  the  infantile  intes- 
tinal tract,  due  to  the  invasion  of  pathogenic  micro- 
organism independent  of  the  form  of  nutrition,  yet 
we  are  obliged  to  acknowledge  that  the  great  and 
principal  source  of  trouble  originates  from  abnormal 
processes  of  fermentation  in  the  milk,  or  in  the  collect- 
ive contents  of  the  intestines,  due  to  germ  life. 

Vaughan  ignores  the  term  "cholera  infantum, " and 
calls  it  "acute  milk  infection, "  claiming  that  it  prac- 
tically never  occurs  with  infants  at  the  breast.  The 
exception,  if  there  be  any,  he  adds,  must  arise  from 
the  introduction  of  powerful  toxicogenic  germs.  En- 
tero-colitis  he  terms  "acute  milk  infection." 

Biggs  refers  to  three  forms  of  intestinal  bacteria, 
which  sustain  causative   relation    to  three   forms   of 


CHOLERA    INFANTUM.  229 

intestinal  summer  troubles.  First,  that  arising  from 
ptomaines  (toxicogenicmicro-org-anisms),  formed  out- 
side of  the  body  and  taken  in  with  food.  To  illus- 
trate: I  was  hastily  summoned  to  a  three-year-old 
child,  who  was  suddenly  awakened  from  sleep  with  a 
most  violent  attack  of  vomiting  and  purging.  Though 
very  severe  for  an  hour  or  more,  it  gradually  subsided. 
The  cause  was  referred  to  some  ice-cream  which  the 
child  had  partaken  of  during  the  evening.  Upon  my 
return  home  I  responded  to  another  urgent  call  to 
find  a  child  similarly  affected,  and  attributed  to  ice- 
cream obtained  from  the  same  source,  and  before 
morning  a  third  case  was  added  to  the  number  injected 
from  the  same  source.  Ptomaines,  tyro-toxicon,  de- 
veloped in  the  ice-cream,  was  introduced  into  the  body 
and  acted  as  a  physiological  poison.  Though  adults 
had  partaken  as  well,  they  were  able  to  resist  patho- 
genic effects.  The  second  class  is  due  to  saprophytic 
bacteria  taken  with  the  food  and  developed  in  the  in- 
testines as  well,  producing  fermentation  and  decom- 
position of  food,  setting  up  inflammatory  conditions. 
The  third  class  is  caused  by  specific  pathogenic  germs, 
producing  powerful  toxicological  effects,  even  to  par- 
alysis, collapse,  cholera. 

Symptomatoiog'y. — Cholera  infantum  is  mostly 
confined  to  the  period  of  dentition,  most  frequent 
during  the  first  ten  months  of  life,  and  among  the 
bottle-fed.  It  diminishes  in  frequency  as  the  child  ad- 
vances in  years,  and  is  rarely  reported  after  the  third 
year.  It  is  sudden  in  its  attack,  rapid  in  its  course, 
and  distressingly  fatal  in  its  results,  exceeding  that 
of  Asiatic  cholera  in  the  adult.     A  prodromal  stage  is 


230  PRESENT    STATUS    OF    PEDIATRICS. 

usually  present,  but  not  always  recognized,  consisting 
of  unusual  restlessness  and  more  or   less   disturbed 
digestion.     If  during  the  heated  season  a  child  under 
two  years  be  suddenly  attacked  with  vomiting  and 
purging  you  would  think  it   due  to  some  article  of 
food,  possibly  fright  or  a  fall  upon  the  head ;  in  either 
instance  the   vomiting   or  purgmg,  or  both,  in  the 
course  of  an  hour  or  two  would  quietly  subside,  but 
if  it  be  violent  and  persistent  we  would  pronounce  it 
cholera  infantum.     Sudden  attacks  of  vomiting  and 
purging  are  not  infrequent  with  children,   but  the 
violence  and  the  persistence  of  the  attack  is  unusual, 
and  is  a  pathognomonic  of  cholera  infantum.     The 
profound  prostration  rapidly  following,  the  extreme 
restlessness,  increasing  and  unquenchable  thirst  and 
abdominal  pain  accompanying,  form   a  combination 
of  symptoms  not  seen  in  any  other  infantile  intestinal 
disease.     The  vomiting  and   purging  continue;  the 
little  one,  who  but  a  few  hours  before  was  rosy  and 
plump,  his   merry    chatter   indicative  of  health  and 
happiness,  is  now  scarcely  recognizable.      The  pale, 
pinched  features,  the  staring  eyes  and  sunken  cheeks, 
the  shrunken  hands,  the  cold  skin  and  clammy  per- 
spiration, the  beseeching  moan  and  half  open  mouth, 
impress  you  with  the  critical  nature  of  the  trouble. 
And  now  follow  cold  breath,  the  almost  imperceptible 
thready  pulse,   the  irregular  and  rapid  respiration, 
tendency  to  cramps  in  the  extremities,  cessation  of 
vomiting,  approaching  drowsiness,    collapse,  convul- 
sions— Cholera.       The    discharges    from    the    bowels 
number   from   twenty    to    forty  in    the    twenty-four 
hours.    After  the  evacuation  of  faecal  matter  they  be- 


CHOLERA    INFANTUM.  23I 

come  colorless,  inodorous,  and  so  serous  as  to  soak 
the  napkin  without  leaving  a  stain.  They  may  con- 
tain a  minute  flaky  substance  of  yellowish-green  with 
a  peculiar  musty  odor.  The  discharges  occur  with- 
out effort,  though  sometimes  accompanied  with  tenes- 
mus, ofttimes  with  considerable  force.  Vomiting 
closely  accompanies  the  action  of  the  bowels,  though 
perhaps  not  so  frequent.  The  stomach  is  excessively 
irritable,  rejecting  with  force  everything  administered, 
followed  by  frequent  and  violent  retching,  appetite 
gone,  but  the  insatiable  thirst  continues.  If  conva- 
lescence be  not  fairly  established  by  the  third  day, 
sequela  may  be  expected.  Approaching  convales- 
cence is  indicated  by  gradual  cessation  of  all  the  vio- 
lent symptoms  first  observed,  diminished  vomiting 
and  retching,  less  thirst,  increased  urine,  decreased 
temperature  and  pulse,  snatches  of  sleep;  a  little 
food  is  retained,  and  the  child  begins  to  manifest  re- 
turning life  and  vitality.  Recovery  may  be  tardy  and 
relapse  not  infrequent. 

Treatment. — In  considering  the  treatment  of 
cholera  infantum,  two  facts  stand  boldly  out,  around 
which  center  the  hopes  and  fears  for  our  little  ones : 
First,  the  sickness  and  mortality  is  largely  confined 
to  the  bottle-fed ;  and  second,  to  the  teething  period. 
It  is  not  necessary  to  elaborate  the  fact  that  so  highly 
organized  nitrogenous  food  as  milk  is  the  most  suit- 
able culture  medium  for  the  reception  and  develop- 
ment of  bacteria.  '» Improperly  fed  infants  furnish 
the  best  known  culture  tube  for  the  growth  of  harm- 
ful bacteria."  It  would  seem  superfluous  to  refer  to 
dangers  seen  and  unseen  in  providing  the  infant  with 


232  PRESENT    STATUS    OF    PEDIATRICS. 

a  suitable  substitute  for  the  natural  breast  milk.  I 
will  simply  refer  to  the  necessity  of  pure  fresh  milk, 
its  care  and  preparation,  that  of  the  bottle  and  all 
that  pertains  to  it,  and  to  the  great  advantage  of  ster- 
ilized or  pasteurized  milk.  Too  much  stress  cannot 
be  laid  upon  these  points,  as  well  as  upon  the  great 
danger  of  overfeeding.  During  hot  weather,  thirst 
is  mistaken  for  hunger,  and  overfeeding  is  the  re- 
sult, with  disastrous  effects. 

Let  there  be  system  and  order  in  the  care  of  the 
little  one,  strictly  observing  every  sanitary  precaution, 
throwing  about  the  child  every  protection  without 
squeezing  the  little  life  into  unreasonable  bounds, — 
the  result  of  undue  fear  and  anxiety.  Plenty  of  pure 
water  should  be  given,  sponge  bathing  at  least  twice 
a  day,  using  water  at  the  temperature  of  ninety,  ad- 
ding a  little  salt.  Avoid  unnecessary  clothing,  bu' 
always  protect  the  "workshop,"  the  abdomen,  by  a 
flannel  or  knit  worsted  band.  All  clothing  should  be 
frequently  changed.  "Sleep  is  Nature's  great  re- 
storer," and  a  child  two  years  of  age  should  receive 
not  less  than  twelve  hours  sleep  out  of  the  twenty- 
four.  Well  ventilated  sleeping  apartments  of  course 
are  preferred,  and  cast-off  garments,  soiled  napkins, 
etc. ,  not  permitted  to  remain  in  the  room.  During 
an  attack  disinfectants  are  indicated.  Fresh  air  and 
sunlight  are  essential  to  health,  a  daily  outing  always 
advisable.  Unnecessary  exposure  must  of  course  be 
avoided.  The  teething  period  renders  the  infant  far 
more  susceptible.  All  of  the  physiological  processes 
are  more  active  as  the  little  organism  is  undergoing 
rapid  development.     The  brain  doubling  its  weight 


CHOLERA    INFANTUM.  2^^ 

during  the  first  two  years  of  life,  is  an  expression  of 
the  rapid  organic  and  functional  changes  going  on. 
Therefore,  everything  that  tends  to  strengthen  and 
invigorate  is  to  be  encouraged,  and  nothing  that  tends 
to  depress  or  enervate  to  be  tolerated — for  the  effect 
of  pathogenic  germs  in  the  system  depend  upon  the 
power  of  organic  resistance. 

Remember  that  improper  food  and  feeding  may  pro- 
duce cholera  infantum  however  hygienic  the  care  and 
management,  and  on  the  other  hand  mother's  milk 
or  the  most  suitable  hand  food  will  not  prevent  chol- 
era infantum  when  other  conditions  necessary  to 
health  are  neglected.  Eternal  vigilance  in  the  ob- 
servance of  a//  of  Nature's  laws  is  the  price  of  the 
life  and  health  of  the  infant. 

Recovery  from  an  attack  of  cholera  infantum  de- 
pends upon  the  inherent  powers  of  the  little  organism 
to  resist  and  overcome  pathogenic  influences  supple- 
mented by  our  efforts  to  support  and  steady  the  eb- 
bing vitality  which  threatens  a  collapse.  ,  To  that  end 
must  be  directed  our  every  effort.  It  calls  for  active 
and  well  defined  ideas  regarding  both  medicines  and 
auxiliary  aids. 

Our  first  order  would  be  to  stop  all  food,  not  a  drop 
of  milk  to  be  given  either  from  breast  or  bottle. 
The  child  is  cold,  has  no  surface  circulation ;  employ, 
without  delay,  suitable  means  to  maintain  and  pro- 
mote animal  heat.  The  child  is  exhausted,  prostrated ; 
employ  every  proper  means  to  support  strength  and 
prevent  collapse.  For  the  promotion  of  warmth  do  not 
resort  to  hot  tub  bathing,  but  wrap  the  child  in  a  warm 
blanket  or  in  a  sheet  wrung  out  in  hot  water  and  en- 


234  PRESENT    STATUS    OF    PEDIATRICS. 

velop  in  a  hot  blanket,  with  hot  water  bags  or  hot 
bottles  about  it.  Give  plenty  of  pure  water  to  drink, 
even  though  it  be  vomited,  and  continue  to  feed  water. 
Do  not  fear  to  stimulate  so  long  as  the  anterior  /on ta- 
nelle  is  depressed,  giving  it  hypodermically,  if  neces- 
sary. Sips  of  hot  water  with  a  few  drops  of  whiskey 
are  in  order,  but  it  is  not  as  gratefully  received,  and 
I  have  never  seen  reason  for  preferring  hot  drinks  to 
cold.  Bits  of  ice  should  not  be  refused ;  iced  tea  or 
a  few  drops  of  black  coffee  are  highly  recommended. 
Let  the  child  rest  in  a  horizontal  position  on  the  bed 
or  pillow,  avoiding  strong  lights  and  disturbing  noises. 
Change  the  napkins  at  once  when  necessary,  and  dis- 
infect them.  As  soon  as  stomach  irritability  suffi- 
ciently abates,  put  the  child  to  the  breast  but  for  a 
moment.  If  bottle  fed,  it  is  far  better  to  secure  a 
wet  nurse,  if  only  for  the  emergency,  and  if  too  fee- 
ble to  nurse,  feed  the  breast  milk  from  a  spoon.  If 
the  wet  nurse  be  impracticable,  dissolve  e^%  albu- 
men in  tepid  water  and  feed  in  sips,  or  soak  a  linen 
rag  in  diluted  cold  cream  and  let  the  child  suck  it. 
Weak  animal  broths — mutton,  chicken,  or  beef — are 
preferable  to  cow's  milk  or  milk  preparations. 

Shall  we  w^ash  out  the  stomach  and  irrigate  the 
bowels?  The  trouble,  though  of  gastro-intestinal 
origin,  is  no  longer  local,  and  is  not  inflammatory. 
The  toxic  effects  are  systemic,  the  absorbing  sur- 
face has  largely  lost  its  powers  of  absorption,  and  so 
long  as  food  is  withheld  we  have  but  little  to  fear 
from  further  infection.  The  excessive  vomiting  has 
emptied  the  stomach  of  its  contents  and  giving  freely 
of  water  to  drink   has  accomplished  all  "washout" 


CHOLERA    INFANTUM.  235 

necessary.  I  cannot  see  any  decided  advantage  in 
any  further  "washout  "  and  can  see  unpleasant  effects. 
Shall  we  irrigate  the  bowels?  If  the  movements  are 
acrid,  very  scant  and  with  tenesmus,  warm  water  in- 
jections containing  j-^'/^Z,  freely  administered,  will  give 
relief.  The  purging  and  vomiting,  though  serious, 
are  not  the  disease.  They  are  secondary,  and  will 
subside  as  the  toxic  condition  exhausts  itself. 

The  first  evidence  of  improvement  will  be  in  the 
decrease  of  vomiting  and  purging,  but  the  improve- 
ment most  to  be  desired  is  the  cessation  of  purging 
and  improvement  in  the  character  of  the  stools.  The 
symptoms  are  many,  but  the  drugs  most  frequently 
indicated  are  few,  and  so  closely  related  as  to  render 
a  scientific  discrimination  no  easy  task.  Not  one  symp- 
tom under  veratruni  but  can  be  found  imder  arseni- 
cuin  and  whichever  you  may  have  given,  if  you  have 
occasion  to  refer  to  your  ''  book,"  you  will  wish  it  had 
been  the  other.  There  are  a  few  well  marked  indi- 
cations, however,  that  will  assist  us  in  a  choice. 
''Arsenicuju  is  the  greatest  of  medicines,  because  the 
greatest  of  poisons."  In  cholera  infantum  we  are 
dealing  with  a  profound  toxic  condition,  with  accom- 
panying severity  of  symptoms. 

Arsenicum  is  indicated  when  there  exists  a  rapid 
sinking  of  vitality,  and  rapid  emaciation,  and  the  least 
exertion  exhausts.  When  this  is  the  marked  feature  of 
the  attack,  arsenicuin  is  the  remedy.  Extreme  rest- 
lessness, suppression  of  urine,  scanty  discharges,  with 
tendency  to  excoriate,  confirm  it. 

When  the  vomiting  and  purging-  is  the  marked  feat- 
tire  of  the  attack,  aggravated  by  the  least  motion, 


236  PRESENT    STATUS    OF    PEDIATRICS. 

I'eratrurn  album  is  the  remedy.  The  exhaustion, 
though  rapid,  the  prostration,  though  marked,  does 
not  equal  that  of  arseniciun.  "In  veratriim  the  case 
is  getting  worse,  in  arscnicuiii  it  is  worse."  The  pe- 
culiar cold  sweat  on  the  forehead,  easily  aggravated, 
is  vcratriivi — while  excessive  restlessness  is  more  pe- 
culiar to  arscnicinn.  Vcratriiui  has  more  pain,  while 
arscnicuin  has  greater  thirst.  Veratrnni  gives  us  all 
the  characteristics  of  cholera  infantum,  and  will  prob- 
ably meet  more  of  the  indications  as  they  usually  ap- 
pear than  any  other  one  remedy.  When  the  case  is 
unusually  severe,  arseniciun  comes  to  the  front. 

When  muscular  cramps  tend  to  aggravate  the  situa- 
tion, C2ipruni  is  to  be  thought  of.  When  the  vomiting 
is  a  distressing  feature,  carbolic  acid  will  be  found  of 
great  service.  Two  or  three  drops  in  a  half  a  glass 
of  water,  half  a  teaspoonful  every  half  hour.  Did  I 
not  know  of  veratrnni  or  arseniciun^  I  would  turn  to 
this  remedy  with  confidence  in  the  general  treat- 
ment. 

I  was  sent  for  to  see  an  infant  at  the  asylum ;  it 
was  not  possible  for  me  to  respond  until  afternoon, 
when  I  found*  the  little  one  much  prostrated  from  an 
attack  of  cholera  infantum.  The  nurse,  weary  of 
waiting  for  my  coming,  and  appreciating  the  necessity 
of  doing  something,  wrapped  the  infant  in  warm 
blankets  and  gave  it  aconite  every  fifteen  minutes. 
Though  at  times  she  thought  the  infant  dying,  she 
continued  the  aconite  and  after  the  second  hour  be- 
gan to  see  some  improvement,  which  had  slowly  con- 
tinued up  to  the  time  of  my  arrival.  vSuppression  of 
urine,  small  evacuations,  extreme  restlessness,  led  me 


CHOLERA    INFANTUM.  237 

to  give  one  dose  of  arsenicuni^  with  directions  to  i^e- 
turn  to  the  aconite  which  had  been  of  such  service. 
The  infant  made  a  good  recovery.  The  nurse  had 
occasion  to  employ  aconite  in  another  case  equally 
severe,  and  with  equally  good  results. 

Subcutaneous  injections  of  chloride  of  sodium  con- 
stitute a  method  which  is  easy  of  application,  and  we 
are  told,  absolutely  harmless,  if  administered  with  an- 
tiseptic precautions.  It  should  be  made  before  col- 
lapse has  reached  a  marked  degree  and  before  the  cir- 
culation has  been  impaired.  It  is  better  to  be  given 
with  the  first  sign  of  collapse,  and  to  repeat  it  as  often  as 
evidences  of  marked  depression  are  observed.  The  so- 
lution should  be  of  the  strength  of  three- fifths  of  one 
per  cent,  the  quantity  to  be  injected,  from  thirty  to 
fifty  grammes.    I  have  never  had  occasion  to  employ  it. 


238  PRESENT    STATUS    OF    PEDIATRICS. 


CHAPTER  XII. 


DIPHTHERIA  AND  SCARLET  FEVER. 

BY  BENJ.  F.  BAILEY,  M.  D. ,  CHAIRMAN  SECTION  OF  P.tDOLOGY, 
AMERICAN  INSTITUTE  OF  HOMCEOPATHY,  1896;  EX-PRESIDENT 
NEBRASKA  STATE  HOMCEOPATHIC  MEDICAL  SOCIETY  ;  MEMBER 
NEBRASKA    STATE   BOARD    OF    HEALTH,   LINCOLN,   NEB. 

DIPHTHERIA  is  now  considered  a  specific,  infec- 
tious, and  probably  contagious  disease. 

Etiolog'y — The  weight  of  authority  seems  to  be 
in  favor  of  the  recognition  of  the  Klebs-Loeffler  ba- 
cillus as  the  specific  germ,  and  hence  cause  of  the 
disease.  This  bacillus  was  discovered  by  Klebs  in 
1883  and  by  Loeffler  in  1884,  and  from  that  time  until 
this  it  has  been  carefully  studied  by  bacteriologists, 
assisted  by  clinicians.  At  this  time  I  am  unable  to 
find  among  the  authorities  one  dissenting  voice  from 
the  Klebs-Loeffier  conclusion  of  1884.  A  few  spo- 
radic writers  deny  the  germ  theory  of  the  disease, 
but  without  being  able  to  suggest  in  its  place  even  a 
reasonable  hypothesis.  During  the  growth  of  the 
bacillus  of  this  disease  there  is  produced  by  it  a  pto- 
maine, a  poisonous  proteid,  and  this,  not  the  bacillus, 
is  the  direct  cause  of  the  symptoms  of  the  disease. 
The  bacillus  is  rarely,  if  ever,  found  in  the  blood  or 
tissues  of  the  body,  except  at  the  point  of  infection. 


DIPHTHERIA.  239 

The  ptomaines  may  be  applied  to  healthy  mucous 
membrane  without  injury,  but  if  once  introduced 
into  the  system  we  may  observe  the  symptoms  and 
poison  of  diphtheria.  That  the  ptomaines  are  the  di- 
rect cause  of  the  disease  is  evidenced  by  the  fact  that 
if  the  bacilli  of  the  diphtheritic  membrane  are  en- 
tirely destroyed,  the  disease  is  still  induced  by  inocu- 
lation with  the  membrane.  It  is  questionable  whether 
the  bacillus  will,  by  itself,  attack  healthy  mucous 
membrane.  If  it  does  not,  it  probably  attacks  sur- 
faces already  injured  by  the  strepto  and  staphylo- 
cocci, or  surfaces  otherwise  denuded.  There  are 
bacilli  that  seem  to  be  identically  the  same  as  the 
Klebs-Loeffler  bacilli,  which  are  found  in  the  throat 
of  seemingly  healthy  subjects.  This  bacillus  has 
been  considered  by  some  to  be  the  bacillus  diphthe- 
riticus,  shorn  of  its  virulence ;  but  it  seems  just  as 
probable  that  it  is  the  virulent  bacillus  resting  upon 
the  mucosa  of  persons  who  are  unsusceptible,  either 
on  account  of  a  healthier,  firmer  texture  of  the  mu- 
cosa itself,  or  from  a  general  immunity  of  the  sys- 
tem. Briefly  stated,  we  may  consider  diphtheria  a 
constitutional  disease,  the  result  of  absorption  of  a 
tox-albumen  from  a  point  of  local  infection.  This 
tox-albumen  has  been  isolated  and  found  by  inocu- 
lation to  induce  all  symptoms  of  constitutional  diph- 
theria that  are  caused  by  the  bacilli.  The  bacillus 
diphtheriticus  retains  its  vitality  at  ordinary  temper- 
ature for  an  unlimited  time,  even  when  dried  in  its 
native  membrane,  or  on  threads,  clothing,  etc.  It 
is  destroyed  at  136.4  F. 
Contagion  and  Incubation.— Contagion  is  prob- 


240  PRESENT    STATUS    OF    PEDIATRICS. 

ably  most  common  from  the  bacilli  coming  in  direct 
contact  with  the  mucous  membrane  of  the  nose,  phar- 
ynx, or  larynx  from  some  person  bearing  within  the 
respiratory  passages  these  elements  of  contagion. 
Infection  may,  however,  take  place  from  bacilli  which 
have  been  carried  even  in  a  dried  state,  upon  inor- 
ganic surfaces.  It  should  be  borne  in  mind  that  not 
only  is  the  diphtheritic  patient  a  source  of  contagion, 
but  the  bacilli  may  be  conveyed  in  the  throats  of 
those  who  have  come  in  contact  with  the  patient,  and 
this  even  though  they  themselves  may  never  develop 
the  disease,  and  that  the  most  malignant  case  may  be 
developed  from  such  a  source. 

The  stage  of  incubation  is  probably  very  short; 
from  a  few  hours  to  a  week  or  ten  days  at  the  longest. 
If  the  present  theory  of  the  disease  is  correct,  it  is 
barely  a  question  of  how  quickly  the  bacilli  may  grow 
and  develop  their  ptomaines  in  the  throat.  They  will 
probably  do  this  either  from  contact  with  an  abraded 
surface,  or  by  the  assistance  of  their  associates,  the 
strepto  or  staphylo-cocci  in  the  above  time,  if  at  all. 

Patholog'y. — Neither  the  pathology  or  morbid 
anatomy  of  diphtheria  seem  to  be  thoroughly  under- 
stood. There  has  never  been  any  satisfactory  article 
upon  this  subject,  and  there  certainly  is  nothing  new 
in  the  literature  of  the  past  year.  We  know  what 
the  lesions  are,  but  we  do  not  adequately  understand 
the  cause  of  these  lesions.  Perhaps  the  most  impor- 
tant change  which  seems  to  be  noticeable,  and  thor- 
oughly demonstrated,  is  an  impoverishment  and 
apparent  defibrination  of  the  blood.  It  seems  to  as- 
sume, in  malignant  cases,  much  the  same  character 


DIPHTHERIA.  241 

as  the  blood  of  persons  poisoned  by  snake  bites.  This 
condition  of  the  blood  is  undoubtedly  the  source  of 
some  of  the  hemorrhages  which  we  occasionally  have 
in  malignant  cases,  and  is  also  probably  largely  the 
cause  of  certain  phenomena  of  the  nervous  system 
which  are  very  frequent.  It  is  hardly  worth  while  to 
attempt  to  say  more  upon  this  subject  until  it  is  more 
thoroughly  understood. 

Clinical  Course. — Diphtheria  may  or  may  not  be 
ushered  in  by  a  chill,  which  may  or  may  not  follow  a 
day  or  two  of  lassitude.  Immediately  supervening 
upon  the  earliest  symptoms,  which,  if  without  chill, 
consists  at  least  of  a  brief  period  of  lassitude,  there 
appears  a  temperature  of  from  loi  to  103  degrees  F. 
The  fever  at  this  time  is  not  infrequently  higher  than 
any  other  time  during  the  course  of  the  disease, 
though  it  may  persist  until  early  convalescence.  This 
is  accompanied  by  general  aching  of  the  back  and  ex- 
tremities. Commonly  within  a  few  hours  one  or  both 
of  the  tonsils  become  reddened  and  covered  Avith  a 
greater  or  less  area  of  a  dirty  white  membranous 
coating.  Of  course  this  membrane  does  not  always 
appear  in  the  throat  first.  It  may  appear  in  the  nares, 
or  it  may  even  appear  in  the  larynx.  If  the  mem- 
brane appears  first  in  the  throat,  the  case  is  at  least 
easily  diagnosed.  From  thence  it  may  spread  either 
to  the  nose  or  larynx,  or  both.  If,  however,  I  may 
be  allowed  to  speak  from  experience,  I  would  say  that 
when  it  spreads  from  the  throat  to  the  nose,  I  rarely 
find  it  tending  to  the  larynx.  On  the  other  hand, 
when  it  tends  from  the  throat  or  pharynx  to  the 
larynx,  I  rarely  find  much  implication  of  the  nares. 
17 


242  PRESENT    STATUS    OF    PEDIATRICS. 

The  course  of  the  disease  is,  in  my  opinion,  governed 
very  largely  by  this  turn.  If  the  membrane  spreads 
to  the  larynx,  our  principal  difficulty  will  be  in  over- 
coming a  condition  of  stenosis  or  obstruction,  and  a 
possible  bronchial  pneumonia,  which  last  condition  is 
probably  due  to  the  associated  germs.  In  this  case 
the  blood  poison  is  not  usually  so  marked,  or  at  least 
not  imtil  a  condition  of  broncho-pneumonia  super- 
venes. On  the  other  hand,  if  the  membrane  tends 
to  invade  the  posterior  nares,  where  we  know  the  ab- 
sorbent vessels  to  be  especially  plentiful,  we  will  very 
likely  avoid  laryngeal  complications,  but  will  usually 
have  to  fight  a  case  of  excessive  malignancy  on  ac- 
count of  the  septic  condition  of  the  blood  which  early 
obtains. 

In  a  work  of  this  kind  it  is  scarcely  necessary  to  go 
into  the  minute  symptoms  of  the  disease,  which  are 
so  familiar  to  every  practitioner,  but  better  to  bring 
out  more  prominently  those  points  which  are  the  re- 
sult of  experience.  The  membrane  ordinarily  in- 
creases in  the  throat  for  the  first  two  to  four  days, 
but  the  fever  is  very  apt  to  remit  to  quite  an  extent, 
and  we  must  not  allow  ourselves  to  judge  our  case 
by  the  temperature,  as  many  very  malignant  cases 
have  a  temperature  running  quite  low.  If  the  case 
progresses  favorably,  we  have  the  throat  beginning 
to  clear  about  the  fourth  day,  with  a  convalescence 
steadily  progressing,  and  usually  reasonably  complete 
in  from  seven  to  ten  days.  In  these  cases  we  usually 
escape  with  very  little  systemic  infection. 

Where  the  disease  does  not  progress  favorably,  but 
tends  from   bad   to  worse,   the  course  is   governed 


DIPHTHERIA,  243 

largely  as  mentioned  above,  by  the  direction  in  which 
the  membrane  seems  to  spread.  If  we  are  to  have 
a  laryngeal  case,  within  from  two  to  four  days  the  exu- 
dation has  usually  reached  the  larynx,  and  we  begin 
to  hear  the  croupy  cough.  This  cough  increases  very 
rapidly,  and  usually  within  forty-eight  hours,  unless 
we  are  able  to  relieve  it,  we  will  see  our  patient  very 
rapidly  succumbing  to  stenosis  of  the  larynx.  Some- 
times however,  in  these  cases,  the  fatality  is  not  so 
much  from  absolute  stenosis  of  the  larynx  as  from 
the  bronchial  pneumonia,  which  is  the  sequela  of  la- 
ryngeal affection. 

Where  bronchial  pneumonia  obtains  a  strong  foot- 
hold, the  course  is  usually  very  rapid  and  very  fatal ; 
and  we  then  begin  to  observe  systemic  infection. 
The  course  of  the  disease  when  we  avoid  bronchial 
pneumonia,  and  only  have  to  combat  laryngeal  steno- 
sis, is  known  by  all ; — gradually  increasing  difficulty 
in  breathing,  croupy  cough,  becoming  higher  and 
harsher  until  the  stenosis  is  so  great  that  even  the 
cough  becomes  but  a  squeak,  depression  of  the  sub- 
clavicular region,  abdominal  respiration,  and  asphyxia. 
These  symptoms  are  not  usually  accompanied  with 
extensive  swelling  of  the  cervical  glands.  On  the 
other  hand,  if  the  membrane  tends  upward,  and 
spreads  through  the  posterior  nares,  we  may  expect 
rapid  absorption  of  septic  material,  and  extensive  in- 
filtration and  swelling  of  the  cervical  glands  of  the 
neck.  There  will  be  a  sanious  acid  discharge  from 
the  nose,  a  rapidly  weakening  heart,  and  probably 
albuminuria.  In  this  case  our  struggle  will  be  largely 
against  septic  infection,  and  the  course  of  the  disease, 


244  PRESENT    STATUS    OF    PEDIATRICS. 

in  these  cases,  where  resolution  does  not  come 
promptly,  but  where  marked  septic  infection  obtains, 
may  at  best  be  prolonged  indefinitely. 

Though  I  have  briefly  outlined  the  probable  course 
of  the  symptoms -as  they  seem  to  me,  let  me  not  be 
misunderstood.  In  any  case  of  diphtheria  the  symp- 
toms may,  and  are  quire  apt  to,  deviate  from  the  ex- 
pected, and  before  the  course  of  the  disease  is  ended, 
combine  more  or  less  intimately  all  known  types. 

Complications  and  Sequelae — Bronchial  pneumo- 
nia is  a  very  common  complication ;  it  is  probably  due 
to  infection  by  strepto  and  staphylo-cocci,  which  we 
have  already  spoken  of,  and  being  the  result  of  sys- 
temic infection,  what  we  have  to  say  under  treatment 
will  be  more  important  than  what  we  could  say  at 
this  point.  Nephritis  proper  is  not  so  common,  but 
albuminuria  is  very  common  in  severe  cases.  Its 
danger  probably  lies  in  the  neglect  of  unrecognized 
conditions  which  gradually  lapse  into  a  chronic  ne- 
phritis. The  tendency,  with  proper  care  and  treat- 
ment, is  to  recovery.  Hemorrhage  from  nose,  throat, 
or  bowels  occasionally  occurs,  and  is  unquestionably 
due  to  defibrination  of  the  blood.  Paralysis  is  a  fre- 
quent accompaniment,  and  may  present  dangerous 
symptoms.  It  is  often  fatal  when,  during  the  course 
of  the  disease,  it  attacks  the  heart  or  respiratory 
organs.  Post- diptheri tic  paralysis,  which  is  probably 
the  result,  usually,  of  a  peripheral  neuritis,  may  be  of 
some  extended  duration,  but  tends  toward  recovery. 
Anaemia  and  chronic  catarrh  are  often  a  more  or 
less  temporary  sequence  of  diphtheria.  Both  should 
yield  readily  to  proper  treatment. 


DIPHTHERIA.  245 

Diagnosis. — In  the  opinion  of  the  writer  there  is 
only  one  thing-  to  be  said  about  positive  diagnosis  of 
diphtheria.  The  only  absolute  method  in  obscure 
cases  is  that  of  the  bacteriologist.  The  only  two  dis- 
eases for  which  diphtheria  is  apt  to  be  mistaken  are 
probably  follicular  tonsillitis  and  so-called  membran- 
ous croup.  Some  of  the  cases  of  so-called  follicular 
tonsillitis,  when  examined  by  the  bacteriologist,  prove 
to  be  undoubted  cases  of  mild  diphtheria,  and  by  con- 
tagion may  induce  cases  of  malignant  diphtheria,  the 
origin  of  which  might  rest  in  obscurity.  At  the  pres- 
ent time  it  is  a  question  in  the  minds  of  many  authori- 
ties whether  or  not  there  is  any  membranous  croup, 
except  of  diphtheritic  origin.  Briefly  stated,  we  may 
find  the  Klebs-Loeffler  bacillus  in  a  person  where 
diphtheria  has  not  developed,  but  we  cannot  find  diph- 
theria without  the  Klebs-Loeffler  bacillus. 

Prog'nosis. — The  prognosis  of  diphtheria  is  very 
uncertain.  Apparently  mild  cases  may  suddenly  be- 
come malignant,  and  apparently  malignant  cases  may 
suddenly  become  rapidly  amenable  to  treatment.  One 
should  always  give  a  guarded  prognosis.  Careful 
study  and  great  watchfulness,  accompanied  by  the 
blessings  of  intuition,  must  be  the  practitioner's  safe- 
guard against  sudden  surprises  which  would  be  a 
source  of  regret  to  him  and  a  cause  of  loss  of  confi- 
dence on  the  part  of  his  patrons. 

Treatment. — I  think  those  who  have  had  any  ex- 
tended experience  in  the  treatment  of  diphtheria  will 
bear  me  out  in  the  statement  that  there  is  no  one 
great  thing  which  has  been  especially  successful  in 
the  management  of  this  disease,  but  rather  the  care- 


246  PRESENT    STATUS    OF    PEDIATRICS. 

ful  attention  to  a  great  many  small  things.  First, 
the  patient  should  be  placed  in  a  well  lighted,  sunny 
room,  with  good,  indirect  ventilation,  and  an  even 
heat ;  the  room  to  be  shorn  of  carpets,  draperies,  and 
all  unnecessary  adornment.  He  should  be  fed  upon 
liquid  food,  of  which  there  is  nothing  better  than  plain 
cow's  milk,  Melliii's  Food,  and  egg-nog.  This  should 
be  given  freely,  in  severe  cases  at  least  as  often  as 
once  in  two  hours.  For  stimulant,  I  say  unqualifiedly, 
give  whiskey,  and  give  it  freely  the  alternate  hours. 
Your  patient  cannot  take  enough  to  intoxicate,  and 
when  he  can,  you  may  have  hope  of  his  recovery. 
There  is  nothing  better  for  the  air  of  the  room  than  a 
continual  spray  of  turpentine  and  eucalyptus  from  a 
steam  atomizer.  If  of  the  laryngeal  type,  it  is  well 
to  keep  lime  continually  slaking  in  the  room.  Have 
the  bowels  move  at  least  once  a  day,  but  always  by 
enema,  never  by  a  laxative.  Let  the  throat  be  kept 
clear  by  a  gargle  or  spray  of  one  part  alcoJiol  and  two 
of  water,  or  listerine,  or  a  mild  permanganate  of  pot- 
ash solution  may  be  used,  but  not  peroxide  of  hydro- 
gen. I  believe  the  so-called  solvents  have  destroyed 
more  than  they  have  saved.  They  have  loosened  the 
membrane,  without  destroying  it,  thereby  spreading 
the  infection. 

The  range  of  remedies  is  still  few,  and  I  would  only 
mention  apis^  arsenicuni,  belladonna,  bromine,  kali 
bicJiromicum,  viercurius  biniodide,  protoiodide,  and 
cyanuret,  Phytolacca,  lac  lie  sis,  and  anti-toxine. 

Beef  marrow  spread  upon  bread  in  the  place  of  but- 
ter is  one  of  the  most  satisfactory  foods  in  the  anaemia 
following  diphtheria.  In  post-diphtheritic  paralysis, 
strychina  and  faradism  may  one  or  both  be  helpful. 


DIPHTHERIA.  247 

In  laryngeal  cases  the  mechanical  obstruction  can 
sometimes  be  relieved  by  intubation.  There  is  a  good 
hope  from  intubation  in  children  of  five  years  or  over, 
not  complicated  by  bronchial  pneumonia.  Under 
five  years  the  chances  grow  rapidly  less,  both  on  ac- 
count of  the  smaller  tube  and  the  lessened  resistance 
to  disease.  In  cities  intubation  is  usually  done  by 
specialists  who  have  become  experts,  but  in  the 
country,  when  this  may  be  impossible,  the  practi- 
tioner should  own  an  intubating  set,  and  study  its  use. 
Nothing  should  deter  him  from  attempting  intuba- 
tion in  a  case  demanding  it,  and  when  he  cannot  sum- 
mon assistance.  At  first  attempt  he  may  find  it  dif- 
ficult to  accomplish,  but  with  a  cool  head  and  careful 
persistence,  many  lives  may  be  saved.  If  the  intu- 
bation is  unsuccessful  in  relieving  the  stenosis,  and 
bronchial  complication  has  not  obtained  too  great  a 
hold,  tracheotomy  should  be  performed. 

Prophylaxis  and  Immunity. — During  the  last 
year  the  theory  of  Iniiniinity  and  the  consequent 
treatment  of  diphtheria  by  anti-toxine  has  been  widely 
discussed  and  has  ardent  supporters  and  defamers. 
The  time  has  not  come  for  an  authoritative  decision 
upon  the  merits  of  either  remedy  or  theory.  The 
country  has  been  flooded  with  hastily  prepared  anti- 
toxine.  We  know  but  little  of  its  purity  or  of  its 
manufacturers.  The  theory  that  a  small  dose  of  the 
poison  inducing  the  disease  may  set  in  action  some 
function,  probably  of  the  blood  corpuscles,  which  in 
turn  will  produce  in  the  blood  serum  itself  a  sub- 
stance which  is  inimical  to  the  disease-producing 
product,  is  the  story  of  Imnnmity.    It  certainly  has  in 


248  PRESENT    STATUS    OF    PEDIATRICS. 

it  a  touch  of  similia^  and  should  claim  the  attention 
and  honest  study  of  the  homoeopathic  school. 

It  is  unnecessary  to  state  here  the  methods  of  using 
anti-toxine^  or  the  dose  of  the  same,  for  the  country 
is  flooded  with  information  of  this  character. 

If  the  theory  of /;;/;;///;/2Vj  should  prove  true,  proph- 
ylaxis, for  a  limited  time  at  least,  is  certain  by  the  use 
of  anti-toxine\  but  we  are  not  justified  in  using  it  for 
this  purpose  until  we  are  more  ^ure  of  its  quality  and 
its  action.  Among  our  own  remedies  it  is  well  to  try 
belladonna  or  one  of  the  mercuries^  but  as  yet  isola- 
tion must  be  our  great  dependence. 

Disinfection. — Disinfection,  as  ordinarily  carried 
out,  is  absolutely  inert.  Wherever  bichloride  solution 
is  used,  let  one  thing  be  borne  in  mind :  it  must  remain 
in  contact  with  whatever  substance  it  is  proposed  to 
sterilize,  from  twenty  minutes  upwards ;  that  its  ac- 
tion upon  germs  or  infectious  tissue  is  absolutely 
chemical,  and  that  after  the  chemical  action  has  used 
up  the  mercury  in  the  formation  of  albunmiate  of 
mercury^  the  solution  is  inert.  We  should  also  re- 
member that  in  fumigation  with  sulphur  it  is  abso- 
lutely without  result,  except  there  be  at  the  same 
time  steam,  or  free  vapor  in  the  room,  which  leads 
us  to  the  conclusion  that  everything  should  be  de- 
stroyed that  is  possible,  and  everything  undestroyed 
should  be  sterilized  by  boiling  water,  where  that  is 
possible.  Nothing  should  be  left  to  sulphur  and  the 
bichloride  solution  except  those  things  that  it  is  im- 
practicable to  treat  by  the  above  methods. 

Future  Promise. —  Six  weeks  after  convalescence 
I  have  taken  germs  from  the  throat  of  a  child.      These 


SCARLET    FEVER.  249 

are  the  cases  that  carry  infection  to  others.  If  every 
case  could  be  studied  bacteriologically,  and  no  case 
of  sore  throat  allowed  to  mingle  with  other  children 
until  bacteriological  examination  showed  it  to  be  en- 
tirely free  from  the  Loeffler  bacillus,  we  would  be 
able,  in  a  short  time,  to  eradicate  diphtheria  from  the 
country.  We  have  paid  too  much  attention  to  fumi- 
gating and  disinfecting  houses  and  too  little  to  steril- 
izing our  patients. 

In  the  light  of  experience,  I  believe  I  am  warranted 
in  stating  positively  that  with  proper  fumigation  of 
the  house  and  surroundings,  and  complete  isolation 
of  the  patient  until  the  germ  has  absolutely  disap- 
peared from  the  mucosa,  we  may  make  every  case  of 
diphtheria  an  isolated  one. 

SCARLET  FEVER  is  probably  a  specific,  infectious, 
and  contagious  disease.  Normally — if  we  may  use 
such  a  term  in  connection  with  any  disease — it  is  prob- 
ably a  self-limited  disease.  In  the  light  of  present 
bacteriological  studies  we  believe  the  disease  to  be 
caused  by  a  specific  germ,  but  this  is  at  present  a 
theory,  and  not  an  authenticated  fact.  Although  much 
search  has  been  made,  a  specific  germ  has  as  yet 
never  been  isolated  and  determined.  The  only  germs 
that  have  been  isolated  in  cases  of  scarlet  fever  have 
been  the  Klebs-Loeffler  bacilli  and  the  strepto  and 
staphylo-cocci.  Their  influence  upon  the  disease  I 
will  consider  more  fully  in  a  proper  place.  The  dis- 
ease is  supposed  by  many  to  be  prevalent  among  some 
animals,  especially  the  cow.  This,  however,  is  not 
positively  settled.     An  attempt  has  been   made  by 


250 


PRESENT    STATUS    OF    PEDIATRICS. 


one  or  two  observers  to  inoculate  with  serum  from 
cows  supposed  to  be  infected  with  the  disease,  hoping 
thereby  to  secure  immunity.  One  Strieker,  of  Or- 
ange, New  Jersey,  has  made  claims  in  this  direction; 
but  inasmuch  as  the  experiments  were  apparently  not 
carried  out  in  a  sufficiently  decisive  way,  and  as  it  is 
not  definitely  decided  that  cows  really  do  suffer  from 
scarlet  fever,  the  results  are  unsatisfactory,  and  are 
only  of  use  as  a  suggestion  for  future  experimental 
work.  The  disease  is  very  common  among  young 
children,  only  a  small  relative  number  escaping  with- 
out scarlet  fever  at  some  time  during  the  early  years 
of  life.  The  first  year  of  life  is  comparatively  ex- 
empt, and  nursing  children  are  considered  especially 
exempt,  and  where  they  do  contract  the  disease,  in 
the  experience  of  the  writer,  it  has  been  in  a  very 
mild  form.  On  the  other  hand,  the  second  year 
seems  to  be  the  most  susceptible  year  of  all. 

Contagion  and  Incubation.  —  Unquestionably 
scarlet  fever  is  an  exceedingly  contagious  disease, 
and  it  has  been  a  matter  of  great  interest  to  the  pro- 
fession, as  it  still  is,  to  decide  at  what  period  of  the 
disease  it  is  most  contagious.  All  writers  seem  to 
differ,  according  to  their  personal  information  and 
experience,  as  to  what  is  the  most  dangerous  period 
of  the  disease.  If  there  is  any  time  that  more  agree 
upon  than  another  it  is  that  the  most  contagious  or 
infectious  stage  is  during  desquamation.  Upon  look- 
ing into  the  matter,  however,  we  find  that  this  seems 
to  be  naught  but  a  theory,  and  with  very  little  to  give 
it  a  foot-hold.  One  can  but  be  inclined  to  feel  that  the 
simple  fact  that  desquamation  is  going  on,  and  that  its 


SCARLET    FEVER. 


251 


results  are  necessarily  more  or  less  scattered  and  dis- 
seminated, is  the  reason  why  it  has  been  generally  be- 
lieved that  there  must  also  be  scattered  and  dissemi- 
nated the  contagion  of  the  disease.  There  is  absolutely 
nothing  to  prove  this,  and  there  are  a  good  many  things 
to  throw  doubt  upon  the  theory.  The  very  facts  that 
the  disease  seems  to  spend  a  great  deal  of  its  force 
upon  the  throat  and  general  mucosa,  and  that  these 
are  the  parts  in  nearly  all  cases  where  we  know  the 
truth,  which  are  more  susceptible  to  infection  than 
others,  and  as  we  know  it  to  be  a  general  and  consti- 
tutional disease,  these  facts,  we  may  repeat,  would  at 
least  give  us  fair  reasons  for  turning  our  search  for 
the  original  cause  of  contagion  to  the  buccal  cavity 
or  the  throat.  But  as  this  is  nothing  but  a  theory, 
and  as  anything  that  I  can  write  would  be  but  the 
suggestions  of  individuals,  without  any  valid  proof, 
it  is  hardly  worth  while  to  spend  any  further  time 
upon  this  subject  at  present.  Without  regard  to 
what  the  co7itaguiin  vivuni  may  be,  we  know  that 
this  disease  is  violently  infectious,  and  that  the  germ, 
if  it  be  a  germ,  is  long  lived  and  hard  of  destruction. 
We  know  that  for  sterilization  by  heat  it  requires  a 
very  high  temperature,  and  that  for  sterilization  by 
chemicals  it  requires  long  contact.  Cases  are  on  rec- 
ord— in  fact,  innumerable  cases — where  infection  has 
been  traced  from  rooms,  clothing,  etc. ,  that  had  not 
been  exposed  to  the  scarlet  fever  contagion  for  many 
months,  or  even  years.  The  period  of  incubation  is 
variously  estimated,  but  is  usually  from  three  to  six 
days.  It  may  be  longer,  and  cases  have  been  re- 
corded where  it  was  definitely  known  that  the  stage 
of  incubation  did  not  exceed  six  hours. 


252  PRESENT    STATUS   OF    PEDIATRICS. 

Pathology.— The  pathology  of  the  disease,  so  far 
as  I  can  learn,  seems  to  depend  largely  upon  the  ef- 
fects of  the  strepto  and  staphylo-cocci.  Of  course  we 
have,  peculiar  to  the  disease  itself,  the  destruction  of 
the  superficial  layers  of  the  skin,  and  a  high  grade  of 
inflammation  in  the  throat,  which  may  go  on  to  a  sup- 
purative or  gangrenous  condition ;  but  I  believe  that 
it  is  probably  true  that  the  milder  types  of  inflam- 
mation of  the  throat,  the  hyperaemic  and  possibly  ca- 
tarrhal condition  of  the  kidne3^s,  and  the  destruction 
of  the  portion  of  the  skin  surface  mentioned,  may  be 
largely  attributed  to  the  specific  disease,  whereas 
more  severe  affections  of  the  throat  and  the  numerous 
sequellcE,  as  parotitis  and  the  suppuration  of  the 
glands,  are  results  entirely  of  the  cocci,  which  be- 
come associated  with  the  disease,  and  yet  cannot  le- 
gitimately be  considered  a  part  of  the  disease.  That 
an  impoverishment  of  the  blood  does  sometimes  take 
place  we  know ;  but  whether  this  is  due  to  the  disease 
proper,  or  its  associated  infections,  no  one  has  ever 
been  able  to  demonstrate. 

Clinical  Course. — Scarlet  fever  is  usually  ush- 
ered in  very  suddenly  by  fever,  occasionally  pre- 
ceded by  a  more  or  less  severe  chill,  and,  in  a  large 
percentage  of  cases,  accompanied  by  vomiting.  At 
this  very  earliest  stage  it  probably  has  been  many 
times  mistaken  for  a  bilious  attack.  Within  from 
twenty-four  to  thirty-six  hours  the  rash  begins  to 
appear,  first  about  the  neck  and  upper  part  of  the 
chest.  From  thence  it  spreads  over  the  body  and  ex- 
tremities, but  is  rarely  marked  much  on  the  face.  The 
rash  usually  completes  its  development  from  the  third 


SCARLET    FEVER,  253 

to  the  fourth  day,  gradually  begins  to  fade,  and  from 
the  sixth  to  the  ninth  day  has  disappeared,  and  des- 
quamation is  established.  The  initial  temperature 
may  vary  from  loi  or  102  to  107  degrees  F. ,  accord- 
ing to  the  malignancy  of  the  attack.  It  rarely  abates 
much  until  the  eruption  is  fully  established  and  begins 
to  fade.  With  the  completion  of  the  fading  of  the 
eruption  and  the  establishment  of  desquamation  the 
temperature  rapidly  returns  to  normal.  Accompany- 
ing the  high  temperature  and  eruption  we  have  an  in- 
flamed throat,  and  a  tongue  which  is  coated  white, 
showing  through  the  white  the  little  red  papillae; 
from  the  fourth  to  the  fifth  day  the  tongue  loses  its 
white  coating,  becomes  red  and  rather  angry  looking, 
and  is  known  as  the  strawberry  tongue.  The  anoma- 
lies in  the  development  of  the  disease  are  excessively 
high  temperature,  tardy  eruption,  and  rapidly  malig- 
nant throat  affections.  If  the  temperature  is  exceed- 
ingly high,  the  rash  may  be  tardy  of  eruption  and 
convulsions  or  coma  may  ensue,  or  the  malignancy  of 
the  disease  may  be  such  that  the  eruption  may  be- 
come exceedingly  dark  and  confluent,  and  ecchymoses 
may  appear  on  different  parts  of  the  body.  Normally 
the  eruption  consists  of  fine  red  points,  which  in  a  well 
developed  case  are  so  close  together  as  to  give  at  first 
the  appearance  of  a  uniform  redness.  The  eruption 
may  present,  according  to  the  case,  all  shades  of 
color,  from  a  light,  innocent  color,  to  the  dark,  even 
almost  bluish  eruption  of  the  malignant  type.  The 
desquamation,  which  begins  on  the  fading  of  the 
eruption,  lasts  from  two  to  four  weeks,  and  is  the 
normal  completion  of  the  disease. 


254  PRESENT    STATUS    OF    PEDIATRICS. 

Complications  and  Sequelae. — The  most  com- 
mon complication  is  the  malignant  type  of  throat  af- 
fection, which  we  often  find  in  this  disease.  I  think 
the  typical  throat  which  belongs  to  scarlet  fever  be- 
gins with  the  earliest  development  of  the  disease,  and 
in  its  course  and  alleviation  follows  out  the  same 
course  as  the  eruption;  but  in  many  cases  I  have 
noted  at  the  close  of  the  fourth  or  beginning  of  the 
fifth  day,  when  the  fever  had  begun  to  abate,  the 
temperature  would  suddenly  rise  again,  the  throat 
would  become  covered  with  a  pseudo  membrane,  the 
cervical  glands  become  much  swollen,  and  we  would 
have  to  combat  a  throat,  and  septic  condition,  much 
resembling  diphtheria.  In  describing  the  throat  of 
diphtheria  in  a  malignant  posterior  nasal  and  pharyn- 
geal case,  we  would  describe  the  condition  which  ob- 
tains here.  However,  we  do  not  always  find  the 
Klebs-Loeffier  bacillus  in  these  cases.  In  fact,  only 
in  a  very  small  percentage  of  cases.  Usually  the  bac- 
teriologist finds  only  the  pyogenic  cocci  to  which  he 
can  attribute  the  condition. 

Acute  parenchymatous  nephritis  is  a  common 
complication  and  a  frequent  sequela.  Some  claim 
that  it  is  always  a  part  of  the  disease.  It  is  a  rea- 
sonable supposition  that  it  is  often  the  sequela  of 
cases  so  mild  as  to  have  been  unrecogni-zed,  and  to 
have  been  considered  nothing  but  mild  attacks  of  fe- 
verishness  until  slight  desquamation  ensued  and  the 
symptoms  of  nephritis  obtained.  If  this  complica- 
tion becomes  marked  during  the  course  of  the  dis- 
ease, we  may  have  uraemia  and  convulsions  as  a  re- 
sult ;  but  if  it  is  a  seqiiela^  we  have  more  to  protect 
our  patient  from  a  resulting  chronic  nephritis. 


SCARLET    FEVER. 


255 


Otitis  is  a  common  complication,  and  undoubt- 
edly the  result  of  infection  by  the  pyogenic  germs 
through  the  eustachian  tube,  extending  from  the 
throat  to  the  middle  ear. 

Synovitis. — Occasionally  synovitis  may  occur,  and 
if  any  symptoms  of  this  affection  be  present,  they 
must  be  very  carefully  and  persistently  combated,  or 
we  are  quite  liable  to  have  a  deformity  of  some  joint. 

Affections  of  the  liver  and  spleen  have  been 
noted,  but  are  not  commonly  of  great  importance. 

Bowels. — A  catarrhal  condition  of  the  bowels  is 
not  infrequently  induced,  and  when  it  does  obtain, 
sometimes  results  in  a  rather  intractable  entero-colitis. 

Anaemia  and  nervous  affections,  as  chorea  and 
epilepsy,  are  at  times  attributed  to  this  disease,  but 
under  modern  care  and  treatment  I  believe  them  very 
rare. 

Diagnosis. — The  diagnosis  of  this  disease,  if  well 
developed,  can  hardly  be  mistaken.  The  only  cases 
where  doubt  can  occur  are  where  a  hyperpyrexia  is 
so  great  that  the  patient  succumbs  in  a  condition  of 
coma  or  convulsions,  before  the  rash  appears.  The 
only  possible  diagnosis  in  such  a  case  must  be  the 
probabilities  arising  from  a  surrounding  epidemic. 
It  might  possibly  be  mistaken  for  diphtheria  in  a  ma- 
lignant case,  but  the  rash  would  probably  obviate  this, 
and  if  it  did  not,  the  disease  and  treatment  of  the 
same  is  so  similar,  that  it  would  not  result  in  any  very 
grave  error.  In  the  mild  cases  arise  the  greatest 
difficulties  of  diagnosis.  Many  times  it  is  wholly 
impossible  to  positively  diagnose  a  case  of  mild 
scarlet  fever  ^^ntil  the  resulting  desquamation  or  al- 


256  PRESENT    STATUS    OF    PEDIATRICS. 

buminuria.  This  being  unquestionably  true,  we 
should  take  great  care  in  the  isolation  of  suspicious 
cases,  and  equally  great  care  in  abstaining  from  criti- 
cism of  cases  which  our  colleagues  may  seem  to  have 
overlooked,  and  in  whose  position  we  might  have  been 
equally  and  excusably  remiss. 

Prog'nosis. — The  prognosis  of  a  normal,  moder- 
ately severe  case  of  scarlet  fever,  with  good  nursing, 
is  good.  The  prognosis  in  malignant  cases  is  bad. 
In  irregular  cases  it  is  uncertain.  If  we  pass  the  firs!, 
days  of  the  eruption  without  malignancy,  we  may 
give  a  good  prognosis,  unless  by  the  fifth  day  a  seri- 
ous throat  complication  is  developed.  If  such  should 
occur  I  believe  that  the  prognosis  should  be  the  same 
as  in  a  case  of  diphtheria  of  apparently  similar  se- 
verity. The  various  complications  should  rarely  oc- 
cur imder  homoeopathic  treatment,  and  if  they  do,  in 
most  cases  it  should  be  possible  for  us  to  avoid  seri- 
ous results. 

Treatment. — First  and  foremost  comes  isolation, 
which  should  be  complete,  and  of  long  duration.  Not 
less  than  six  weeks.  In  hyperpyrexia  hot  baths  may 
be  used,  and  if  this  is  unsuccessful  a  bath  of  100  de- 
grees F. ,  the  temperature  being  gradually  decreased 
to  from  65  to  75  degrees.  This  treatment  is  advised 
by  many  of  the  best  authorities,  although  the  impres- 
sion of  the  writer,  after  a  reasonably  large  experi- 
ence, would  lead  him  to  believe  that  better  results 
will  be  obtained  from  adhering  to  the  administration 
of  the  indicated  homoeopathic  remedies.  This  must 
of  course  be  left  to  the  judgment  of  each  practitioner. 
Frequent  tepid  sponge  baths  of  one  part  alcoJwl  to  four 


SCARLET    FEVER.  257 

or  five  of  water  are  very  comforting  to  the  patient, 
and  seem  to  alleviate  the  restlessness.  During-  des- 
quamation, as  a  matter  of  prevention  of  contagion, 
and  also  of  protection  of  the  skin  surface,  we  know 
of  no  better  method  at  present  than  the  rubbing  of 
the  child  daily  in  a  carbolized  olive  oil.  The  diet 
should  be  liquid  until  convalescence  is  thoroughly 
established,  and  I  would  recommend  milk,  MelliiCs 
Food,  and  unfermented  grape  juice.  For  the  local 
treatment  of  the  throat  I  can  commend  nothing  better 
than  the  same  treatment  I  would  give  for  a  similar 
case  of  diphtheria,  for  vv^hich  I  refer  you  to  the  paper 
on  that  subject.     (wSee  page  245.) 

Remedies. — For  remedies  I  would  mention  ailari- 
tlius,  amnioniutncarboniciLm,  apis  mcllifica^  arseniciun^ 
anuji  tripJiyllum,  belladonna,  calcarea  carbonica,  cam- 
phora,  carbolic  acid,  cupriun,  digitalis,  gelsemiuvi, 
Jielleboriis,  hepar,  hyoseyamus,  muriatic  acid,  nitric 
acid, Phytolacca,  sulphur,  veratrum  viride,  and  zincum. 

It  is  wise  to  give  the  child  freely  of  water.  I  be- 
lieve distilled  water  is  the  best.  Unquestionably  this 
may  help  obviate  the  tendency  to  nephritis. 

Prophylaxis.  —  For  many  years  our  profession 
has  discussed /r^  and  coji  the  question  of  prophylaxis 
in  scarlet  fever.  Some  have  claimed  belladonna  to 
be  of  great  benefit;  others  have  ridiculed  it.  For 
nearly  seven  years  the  writer  has  had  under  his  charge 
an  orphanage  in  which  the  number  of  orphans  has 
averaged  seventy-five.  On  three  different  occasions 
during  that  time  I  have  had  scarlet  fever  break  out 
in  the  institution.  The  first  outbreak  with  one  case, 
the  second  with  two  cases.  I  immediately  put  every 
18 


258  PRESENT    STATUS    OF    PEDIATRICS. 

child  in  the  institution  upon  three  doses  of  belladonna 
a  day.  No  other  cases  followed.  I  have  but  once  in 
my  practice  known  a  case  of  scarlet  fever  to  ensue 
after  the  administration  of  belladonna^  and  that  case 
was  very  mild  in  character.  This  is  but  a  straw,  but 
it  is  well  worth  consideration. 

Disinfection. — I  would  refer  the  readers  to  the 
article  upon  diphtheria  for  what  I  have  to  say  upon 
disinfectants.  (See  page  248. )  I  could  only  repeat 
exactly  the  same  things,  and  I  believe  that  comprises 
in  a  few  words  the  present  status  of  disinfection,  fu- 
migation, and  sterilization. 

Future  Promise. — Scarlet  fever,  like  diphtheria,  is 
an  avoidable  disease,  and  every  case  of  avoidable  dis- 
ease that  occurs  is  the  fault,  innocently  or  guiltily,  of 
someone.  We  have  boards  of  health  and  quarantine 
laws  galore.  We  have  also  people  who  are  solicitous 
for  the  welfare  of  their  own  children ;  but  we  lack,  as 
a  people,  that  realization  of  our  duty  toward  others 
that  would  make  it  possible,  or  might  make  it  possi- 
ble, to  entirely  eradicate  such  diseases  as  scarlet  fe- 
ver. If,  while  at  the  same  time  that  we  make  quar- 
antine laws,  we  spend  a  good  deal  of  time  in  teach- 
ing our  people,  not  in  a  public  way,  resulting  in 
personal  advertisements  in  the  press,  but  in  a  quiet, 
earnest,  and  honest  argumentative  work  among  our 
patients  and  our  colleagues,  we  can  lead  them  to  see 
and  .understand  the  objects  of  quarantine,  and  the 
best  methods  of  carrying  it  out  and  the  absolute  neces- 
sity of  complete  isolation  of  contagious  cases,  so  that 
it  may  be  possible  for  us  to  make  every  case  of  scar, 
let  fever,  as  of  diphtheria,  an  isolated  one,  and  in  a 
few  years  it  may  be  made  so  rare  a  disease  that  its 
chief  interest  will  be  in  its  history. 


TYPHOID    AND    REMITTENT    FEVER.  259 


CHAPTER  XIII 


TYPHOID    AND    REMITTENT    (MALARIAL) 
FEVER. 

BY  ALLISON  CLOKEY,  M.  D. ,  SECRETARY  SECTION  OF  P.'EDOLOGY, 
AMERICAN  INSTITUTE  OK  IIOMCEOPATHY,  1896;  PRESIDENT  KEN- 
TUCKY STATE  SOCIETY  ;  REGISTRAR  AND  PROFESSOR  OF  PHYSI- 
OLOGY, SOUTHWESTERN  HOMCEOPATHIC  MEDICAL  COLLEGE, 
LOUISVILLE,  KENTUCKY. 

In  GeneraL — Typhoid  and  remittent  fever  play 
so  important  a  part  in  the  practice  of  the  general 
practitioner,  and  every  physician  who  has  them  to 
deal  with  is  so  familiar  with  their  every  phase,  that  a 
consideration  of  them  in  this  connection  seems  al- 
most superfluous.  No  attempt,  therefore,  will  be 
made  to  treat  the  subj.ect  exhaustively,  but  only  a  few 
observations  will  be  offered  which  every  physician 
who  practices  in  a  malarial  locality  has  doubtlessly 
made  for  himself. 

Pathology. — We  seriously  question  whether  ty- 
phoid and  remittent  fever  deserve  a  place  in  a  work 
devoted  exclusively  to  diseases  of  children.  As  a 
matter  of  fact  we  know  that  they  are  much  more 
common  among  adults,  to  which  w^e  would  add  that 
remittent  fever  is  relatively  more  common  in  either 
case.  It  is  a  well  known  fact  that  the  agminated 
glands  which  are  the  seat  of  the  specific  lesion  of  ty- 
phoid fever  are  undeveloped  during  the  early  years 


26o  PRESENT    STATUS    OF    PEDIATRICS. 

of  life,  and  for  this  reason  we  are  told  that  it  is  not 
until  about  the  fifteenth  year  that  age  becomes  a  pre- 
disposing cause  of  typhoid,  the  years  between  fifteen 
and  twenty-five  being  those  in  which  the  disease  most 
frequently  occurs.  We  would  throw  out  a  thought  in 
this  connection  which  has  frequently  occurred  to  us 
in  the  study  of  typhoid  fever. 

Jacobi  says:  "The  groups  called  Peyer's  patches 
are  very  imperfect  in  children — so  much  so  that  they 
are  not  liable  to  disease ;  and  typhoid  fever,  in  which 
they  are  invariably  inflamed,  is  extremely  rare  in 
children."  Is  the  inflammation  of  Peyer's  patches 
the  sine  qua  non  of  typhoid  ?  If  not,  how  does  their 
imperfect  development  in  early  life  account  for  the 
infrequency  of  typhoid  during  these  years  ?  We  un- 
derstand that  typhoid  is  a  specific  systemic  infection 
in  which  the  blood  is  the  first  tissue  affected,  the  le- 
sions in  the  intestines  and  elsewhere  being  secondary 
to  the  blood  changes. 

Loomissays:  "As  soon  as  the  disease  is  fully  es- 
tablished a  change  in  the  blood  occurs.  In  connec- 
tion with  these  blood  changes,  a  series  of  changes 
take  place  in  those  organs  and  tissues  of  the  body  in 
which  the  process  of  waste  and  repair  are  most  rapidly 
going  on."  If  this  be  correct,  how  can  the  condition 
of  Peyer's  patches  in  the  child  play  any  part  in  his 
seeming  immunity  from  typhoid  fever? 

We  do  not  believe  at  any  rate  that  typhoid  and  re- 
mittent fever  in  the  child  differ  in  any  way  from  the 
same  disease  in  the  adult,  and  in  the  following  pages 
they  will  be  considered  in  the  abstract  without  refer- 
ence to  age. 


TYPHOID    AND    REMITTENT    FEVER.  26 1 

Diag'nosis. — In  the  study  of  the  peritoneum  we  are 
taught  as  students  to  trace  the  two  layers,  anterior 
and  posterior,  together,  following  them  from  the  un- 
under  surface  of  the  diaphragm  to  the  upper  sur- 
face of  the  liver,  around  the  liver  in  front  and 
behind,  down  to  the  stomach  and  around  it  in  front 
and  behind,  down  in  front  of  the  intestines  and 
back  again  to  form  the  greater  omentum,  and  thence 
to  the  transverse  colon,  where  the  two  layers  part 
company,  the  one  going  up  and  the  other  down.  Ty- 
phoid and  remittent  fever  follow  in  many  respects  so 
nearly  the  same  clinical  course  that  it  occurs  to  us 
that  they,  like  the  two  layers  of  the  peritoneum,  may 
well  be  studied  together,  the  points  where  they  differ 
only  serving  to  emphasize  their  resemblance  through- 
out the  rest  of  their  course. 

To  the  mind  of  the  ph3^sician,  who  practices  in  a  ma- 
larial locality,  almost  the  first  question  that  presents 
itself  in  connection  with  a  case  of  continued  fever  is  "  Is 
it  typhoid  or  remittent?"  To  those  who  practice  in 
localities  free  from  malaria,  where  typhoids  pursue  a 
typical  course,  this  question  may  seem  an  ignorant 
one.  Our  text-books  draw  such  easy  lines  for  diag- 
nosis between  typhoid  and  remittent  that  one  should 
feel  almost  ashamed  to  confess  that  he  was  not  quite 
certain  of  his  case,  especially  when  he  has  had  it 
under  observation  from  the  beginning. 

In  malarial  climates  we  see  but  few  typical  typhoids, 
and  the  possibility  of  the  fever  being  remittent  often 
makes  the  diagnosis  not  only  difficult,  but  sometimes 
almost  impossible.  The  writer  has  had  cases  which 
he  has  seen  twice  daily  from  start  to  finish,  in  which. 


262  PRESENT    STATUS    OF    PEDIATRICS. 

even  after  convalescence  was  thoroughly  established, 
he  was  unable  to  say  positively  whether  it  had  been  ty- 
phoid or  remittent.  A  case  in  point  might  be  men- 
tioned— that  of  a  lady,  for  example,  whose  fever  ran 
four  weeks,  the  temperature  curve  being  characteristic 
of  neither  typhoid  or  remittent.  There  was  nothing 
positive  about  the  appearance  of  the  tongue.  The 
condition  of  the  bowels  was  not  suggestive.  There 
was  no  eruption ;  no  somnolence  or  delirium.  There 
was  but  little  exhaustion  and  emaciation.  One  day 
we  diagnosed  the  case  typhoid,  only  to  change  to  re- 
mittent the  next,  and  after  convalescence  was  estab- 
lished, in  the  fifth  week,  we  were  as  uncertain  of  our 
diagnosis  as  at  any  time  during  the  course  of  the 
case.  Upon  the  first  departure  from  a  strictly  liquid 
diet,  several  days  after  the  temperature  had  become 
normal,  intestinal  hemorrhages  occurred,  and  the  pa- 
tient had  a  relapse.  The  diagnosis  was,  alas !  finally 
clear.  The  Peyer's  patches  were  involved.  It  was 
typhoid. 

In  our  work  at  the  city  hospital,  where  the  cases  of 
continued  fever  come  in  usually  after  they  have  run 
a  week  or  longer,  it  is  sometimes  with  the  greatest 
difficulty  that  we  can  diagnose  between  a  mild  case  of 
typhoid  and  a  severe  case  of  remittent  fever.  In 
such  cases  we  are  frequently  assisted  in  clearing  up 
the  diagnosis  b)"  cautiously  feeding  the  patient  a  little 
solid  food,  a  dry  cracker  for  instance.  If  the  case  be 
typhoid,  a  rise  in  temperature  almost  immediately 
follows,  owing  to  the  irritation  of  the  inflamed  agmi- 
nated  patches,  whereas  no  exacerbation  occurs  if  it 
be  a  case  of  remittent  fever. 


TYPHOID    AND    REMITTENT    FEVER.  263 

It  is  claimed  by  some  writers  that  the  diagnosis 
of  typhoid  cannot  be  made  with  positiveness  imless 
there  be  the  typical  temperature  range  and  the  erup- 
tion. If  that  be  the  case,  we  have  but  little,  if  any, 
typhoid  in  the  location  Avhere  the  v/riter  lives.  We 
seldom  even  look  for  the  eruption,  nor  do  we  consider 
a  departure  from  the  classical  temperature  range  in- 
compatible with  a  diagnosis  of  typhoid.  Our  typhoids 
are  typho  malarial,  in  which  the  typical  evening  rise 
of  temperature  is  exaggerated  by  the  malarial  com- 
plication. In  making  our  diagnosis  we  must  depend 
upon  the  general  en  scinblc  of  the  case,  which  is  usu- 
ally characteristic  enough  for  the  purpose  of  differ- 
entiation. The  dry  brown  tongue,  the  tender  and 
tympanitic  abdomen,  the  delirium,  the  emaciation 
and  prostration  carry  us  away  from  remittent  fever 
and  into  typhoid;  and  yet  these  features  are  fre- 
quently so  indistinct  in  a  mild  case  of  typhoid,  and 
are  so  frequently  present  in  a  severe  case  of  remit- 
tent, that  it  is  difficult  to  make  the  diagnosis. 

However  much  typhoid  and  remittent  fever  may 
seem  to  overlap  in  their  general  appearance,  they  are 
etiologically  and  pathologically  quite  separate  and  dis- 
tinct. We  have  before  us  a  recent  work  on  pedi- 
atrics in  which  "infantile  typhoid  fever"  and  ''in- 
fantile remittent  fever  "  are  mentioned  as  synonyms. 
We  are  not  at  all  in  sympathy  with  this  classification. 
Aside  from  the  fact  that  we  do  not  consider  infantile 
typhoid  and  infantile  remittent  as  distinct  types,  we 
are  certain  that  etiology  and  pathology  carry  the  two 
fevers  away  from  each  other,  no  matter  how  closely 
their  clinical  course  and  therapeutics  may  approach. 


264  PRESENT    STATUS    OF    PEDIATRICS. 

Treatment. — The  treatment  of  typhoid  fever  and 
remittent  fever  have  so  much  in  common  that  it  must 
be  quite  a  consolation  to  the  physician  who  is  in  doubt 
of  his  diagnosis.  In  a  doubtful  case  the  patient  will 
of  course  be  placed  on  liquid  diet,  which  should  be 
rigidly  adhered  to  as  long  as  any  doubt  exists.  The 
therapeutics  of  the  two  fevers  is  definite,  and  the 
writer  would  not  go  into  a  tiresome  detail  of  all  of 
the  remedies  which  have  stood  the  test  of  repeated 
trials.  Every  physician  has  these  remedies  and  their 
indications  at  his  finger  ends.  In  this  article  only 
two  remedies  will  be  mentioned,  which  from  their 
service  in  both  typhoid  and  remittent  are  absolutely 
indispensable  to  the  physician  who  practices  where 
malaria  abounds.  They  are  gclseinmin  and  arseni- 
cinn. 

Gelseniiitin  is  one  of  our  very  best  remedies  in  the 
first  days  of  typhoid,  especially  typho-malaria,  and  in 
mild  cases  is  often  the  only  remedy  needed  through- 
out ;  in  remittent  fever  it  is  the  remedy  par  excel- 
lence. In  hospital  practice  the  writer  has  learned  to 
place  the  utmost  confidence  in  gelsemiuin.  After 
trying  other  remedies,  he  has  come  to  the  conclusion 
that  no  other  remedy  acts  half  so  well  in  remittent 
fever.  Other  cases,  similar  in  every  respect,  treated 
homoeopathically  with  other  remedies  as  they  seemed 
indicated  from  day  to  day  did  not  recover  so  promptly 
as  those  kept  on  gclseiiiiuju  throughout.  The  more 
nearly  the  symptoms  of  a  mild  case  of  typhoid  ap- 
proach remittent  fever  the  better  is  gelseiiiiiiin  indi- 
cated 

In    either   typhoid  or  remittent   fever,  where   the 


TYPHOID    AND    REMITTENT    FEVER.  265 

intoxication  of  the  system  is  too  profound  for  gel- 
semiurn^  as  shown  by  persistency  of  the  fever  or  by 
great  exhaustion,  arseiiicjun  takes  the  place  occupied 
by  the  former  remedy  in  the  treatment  of  the  milder 
forms.  Persistent  temperature  or  progressing  adyna- 
mia are  the  indications  that  should  lead  to  the  substi- 
tution of  arsenicum  for  gelseinium.  We  believe  that 
the  pathology  of  typhoid  and  remittent  fever  support 
the  selection  of  these  two  remedies.  In  either  case 
we  have  an  intoxication  of  the  system  by  a  specific 
infection ;  the  whole  system  is  infected,  and  then  in 
typhoid  fever  the  specific  lesions  appear  in  the  intes- 
tines ;  but  we  do  not  understand  that  the  course  of 
typhoid  is  determined  by  the  extent  of  these  lesions. 
In  other  words,  the  intestinal  changes  do  not  consti- 
tute the  pathology  of  typhoid;  that  is  rather  the 
changes  in  the  blood  just  as  in  the  case  of  the  mala- 
rial fevers,  remittent  or  intermittent. 

In  the  gclseniiuni  case  of  either  typhoid  or  remit- 
tent fever  the  poison  spends  its  force  on  the  circula- 
tory centers,  and  we  have  that  relaxation  without 
much  emaciation  which  is  common  in  a  mild  case  of 
either  fever.  In  the  arsenicum  case  the  poison  at- 
tacks the  nerve  centers,  and  we  have  that  intense 
prostration  and  emaciation  which  indicate  that  the 
very  centers  of  organic  life  have  been  seriously  af- 
fected. We  say  that  although  the  etiology  of  the  two 
fevers  differ,  and  although  we  have  specific  lesions  in 
the  one  fever  and  none  in  the  other,  yet  the  same 
centers  are  attacked  and  in  very  much  the  same  way 
by  both  poisons.  If  this  reasoning  be  correct  the  two 
remedies  mentioned  are  as  homoeopathic  to  typhoid 
as  to  remittent  fever.  In  prescribing  upon  the  pa- 
thology of  the  case  we  must  not  be  misled  by  the  fact 
that  the  etiologies  differ. 


266  PRESENT    STATUS    OF    PEDIATRICS. 


CHAPTER  XIV. 


ORTHOPEDIC  SURGERY. 

BY  HOWARD  ROY  CHISLETT,  M.  D.,  PROFESSOR  OF  SURGERY  IN  HAHN- 
EMANN COLLEGE  AND  HOSPITAL;  ATTENDING  SURGEON  TO 
HAHNEMANN  AND  COOK  COUNTY  HOSPITALS,  CHICAGO,  ILLI- 
NOIS. 

General  Considerations.  —  Orthopedic  surgery 
deals  with  the  deformities  of  the  body,  their  preven- 
tion and  their  cure.  The  frequency  of  such  deformi- 
ties among  children  renders  orthopedics  quite  as  much 
an  integral  part  of  pediatrics  as  of  general  surgery. 
The  nature  of  a  book  of  this  description  sets  its  own 
limitations.  These  must  excuse  to  the  hypercritical 
the  conciseness  of  expression.  Historical  references 
are  purposely  omitted,  and  no  space  will  be  lost  in  the 
discussion  of  the  comparative  value  of  methods.  The 
author  prefers  to  describe  those  only  which  have 
proved  satisfactory  in  his  own  experience.  Classifi- 
cations are  unsatisfactory  and  misleading,  except  to 
their  authors;  each  subject  will  therefore  be  treated 
under  its  own  special  heading. 

Diag'nosiS. — In  no  department  of  medicine  or  sur- 
gery is  diagnosis  of  greater  importance.  Diagnosis 
is  the  essential  element  of  satisfactory  treatment  and 
correct  prognosis.  This  means  diagnosis  in  its  broad- 
est sense  and  includes,  first,  the  recognition  of  causes 


ORTHOPEDIC    SURGERY.  267 

both  predisposing  and  exciting;  second,  the  exact 
recognition  of  the  structures  involved  and  their  nor- 
mal anatomy  and  physiology ;  third,  the  knowledge  of 
the  ways  in  which  their  present  condition  differs  from 
the  normal.  These  are  the  essential  factors  of  suc- 
cess, mechanics  will  do  the  rest.  It  is  not  necessary 
to  enter  into  a  description  of  the  many  instruments 
and  appliances  now  used  by  specialists  in  this  branch 
of  surgery  as  aids  in  accurate  diagnosis  and  examin- 
ation ;  for  these,  larger  works  must  be  consulted. 

Causes. — The  proper  discussion  of  general  causes 
is  more  easy  if  we  make  a  division  of  deformities  into 
the  congenital  and  the  acquired. 

T.  Heredity. — Though  playing  a  far  less  impor- 
tant part  than  was  formerly  supposed,  heredity  cannot 
be  entirely  disregarded.  Many  instances  of  family 
deformities  have  been  reported ;  club  feet,  supernu- 
merar}'-  digits,  and  congenital  dislocations  being  es- 
pecially common. 

2.  Maternal  Impressions. — Though  imperfectly 
understood,  "marked"  children,  as  the  result  of 
fright  during  early  pregnancy,  are  not  unknown. 

3.  Faulty  Development. — This  maybe  a  primary 
defect  in  formation,  or  it  may  be  a  secondary  inter- 
ference in  the  development  of  a  normally  formed 
foetus,  through  loups  in  the  umbilical  cord,  or  from 
abnormal  intra-uterine  pressure,  either  from  a  faulty 
position  of  the  foetus,  or  from  too  limited  a  supply  of 
amniotic  fluid. 

4.  Injuries  or  Diseases. — During  intra-uterine  life, 
fractures  from  external  traumatism  with  union  in  an 
abnormal  position  are  not  infrequent.     Rhachitis  is 


268  PRESENT    STATUS    OF    PEDIATRICS. 

regarded  as  the  disease  most  commonly  accountable 
for  deformities  during  intra-uterine  life. 

The  Acquired. —  i.  Pressure  Effects. — Some  cases 
of  nearly  every  acquired  deformity  may  be  traced  to 
unequal  pressure  during  active  growth.  The  growth 
being  normally  active  where  not  subjected  to  undue 
pressure,  and  very  slow  if  not  actually  arrested  where 
the  pressure  is  very  great.  The  effect  is  an  asymet- 
rical  development,  whether  arising  from  an  unequal 
length  of  the  limbs,  from  habits  of  standing  or  sitting 
in  bent  or  slouchy  positions,  or  from  paralysis  of  one 
group  with  contraction  of  the  opposing  group  of  mus- 
cles. 

2.  Injuries. — Fractures  improperly  set  and  cared 
for;  dislocations  unrecognized  and  consequently  unre- 
duced; nerve  injuries  resulting  in  paralysis. 

3.  Diseases. — Joint  diseases  of  an  inflammatory 
nature  resulting  in  ankylosis  in  faulty  position. 
Large  destruction  of  soft  tissues  with  the  consequent 
cicatricial  contractions.  Central  or  peripheral  nerve 
lesions  insufficient  to  produce  complete  paralysis  may 
cause  either  spasm  or  atrophy  of  muscles  or  ankylo- 
sis of  joints.  Certain  muscular  contractions  are  with- 
out doubt  also  caused  by  reflex  nerve  irritation. 

Symptoms  and  Pathology. — As  the  symptoms 
are  usually  mainly  objective^  a  general  consideration  is 
uncalled  for.  The  symptomatology  will  be  consid- 
ered with  each  special  deformit}^  in  the  proper  place. 
In  general  pathology  there  are  a  few  points  which 
cannot  be  too  strongly  emphasized.  Too  much  stress 
has  been  laid  upon  muscles  and  tendons  as  the  main 
factors  in  the  causation  and  perpetuation  of  deformi- 


ORTHOPEDIC    SURGERY,  269 

ties.  The  fact  is  that  no  matter  how  great  a  part 
these  structures  may  play  in  the  causation  of  deform- 
ity, the  real  obstacle  to  be  overcome  in  most  deformi- 
ties of  the  trunk  and  limbs  is  an  alteration  in  the 
shape  or  in  the  relationship  of  the  bones  themselves. 
Rational  treatment  must  be  based  upon  a  clear  recog- 
nition of  causation  and  pathology. 

General  Tpeatment. — The  key-note  to  success  in 
the  majority  of  cases  maybe  summed  up  in  the  words 
equalization  of  pressure.  To  attain  this  end  many 
varieties  of  methods  must  be  employed  either  alone 
or  in  combination.  Nothing  is  more  certain  than 
this :  No  one  method  of  treatment  will  be  found  suit- 
able for  all  cases.  Constitutional  treatment  is  in 
many  cases  quite  as  essential  as  the  local.  It  should 
include  careful  attention  to  hygienic  surroundings, 
diet,  and  habits,  physical  culture  in  general,  and  of 
the  involved  parts  where  necessary.  This  latter 
should  include  passive  movements,  massage  and  elec- 
tricity when  called  for,  and  postural  treatment  must 
not  be  overlooked.  It  would  be  manifestly  impossi- 
ble to  even  name  the  variety  of  mechanical  agents 
used  in  the  correction  of  these  orthopedic  cases. 
Those  which  are  especially  useful  will  receive  due 
consideration. 

Orthopedic  Operations. — The  number  of  opera- 
tions for  the  correction  of  deformities  and  their  causa- 
tive diseases  has  been  steadily  increasing  since  the 
advent  of  the  antiseptic  methods.  The  success  met 
with  is  very  gratifying;  enough  so  at  times  to  en- 
danger a  loss  of  sight  of  the  less  brilliant,  though  in 
some  respects  the  more  satisfactory,  methods  of  man- 


270  PRESENT    STATUS    OF    PEDIATRICS. 

ual  correction  and  elastic  traction.  It  is  only  nec- 
essary here  to  mention  the  more  common  ones ;  te- 
notomy, myotomy,  osteotomy,  simple  and  cuneiform, 
chondrectomy,  and  excision.  They  will  each  be  de- 
scribed as  fully  as  necessary  in  the  cases  where  they 
may  be  found  not  only  useful  but  necessary. 

TORTICOLLIS.— Torticollis,  or  wry  neck,  is  a  de- 
formity produced  by  a  contraction  of  the  sterno- 
cleido-mastoid  muscle. 

Causes. — Some  authors  describe  a  congenital  form 
due  either  to  injury  at  birth  or  to  malposition  in  utero. 
Those  usually  seen  are  acquired  and  may  be  the  re- 
sult of  holding-  the  head  too  long  in  this  faulty  posi- 
tion owing  to  cold  or  rheumatism,  to  irritation  of  the 
spinal  accessor}^  nerve  by  growing  tumors  or  from 
central  disease,  or  it  may  follow  cicatricial  contrac- 
tions following  injuries  to  the  sterno-mastoid  muscle 
itself. 

Symptoms. — The  head  is  drawn  forward  and  to- 
ward the  diseased  or  injured  side,  but  rotated  so  that 
the  chin  points  to  the  opposite  shoulder.  In  cases  of 
long  duration  there  is  usually  a  lateral  deviation  of 
the  spine  in  the  cervical  region,  the  convexity  being 
to  the  opposite  side.  When  very  pronounced  there 
will  naturally  follow  a  compensatory  dorsal  curve 
with  the  convexity  toward  the  diseased  side. 

Treatment.— This  must,  of  course,  depend  upon 
the  causation.  In  the  congenital  form,  unless  it  be 
due  to  spastic  contraction  from  central  disease,  mass- 
age and  kneading  the  involved  muscle  will  generally 
bring  about  a  satisfactory  result  in  a  few  weeks.  The 
rubbing   must    be    thorough  and    the  head   held   in 


ORTHOPEDIC    SURGERY.  27  I 

proper  position  for  some  minutes  after  each  treat- 
ment. In  bad  cases,  after  correction,  it  may  become 
necessary  either  to  apply  a  starch  or  plaster  bandage, 
or  to  use  the  elastic  traction  as  described  below.  If 
not  treated  early,  myotomy  may  be  demanded.  The 
acquired  form,  if  resulting-  from  cold,  will  usually  re- 
spond readily  to  heat,  massage,  and  the  indicated 
remedy — most  frequently  bryonia^  ferrum  pJiosphori- 
cuin^  arnica^  and  rJuis  toxicodendron.  If  resulting 
from  local  nerve  irritation,  the  cause  of  pressure,  the 
developing  glands  or  tumors,  should  be  excised.  If 
the  nerve  irritation  is  central,  nerve  stretching  may 
be  first  tried,  and  this  failing,  the  excision  of  a  por- 
tion of  the  nerve  just  before  it  enters  the  anterior 
portion  of  the  sterno-mastoid  is  advisable.  This 
point  is  one  inch  below  the  tip  of  the  mastoid,  and 
the  nerve  is  readily  reached  by  an  oblique  incision 
along  the  anterior  border  of  the  muscle. 

Cases  due  to  cicatricial  contraction  may  be  treated 
by  kneading  and  stretching  or  by  plastic  operations. 
Myotomy  is  called  for  only  in  such  cases  where  the 
muscle  has  undergone  so  pronounced  an  adaptive 
shortening  that  the  massage  and  stretching  have  ut- 
terly failed.  The  muscle  should  be  divided  by  pref- 
erence through  an  open  incision  just  above  the  clavi- 
cle. This  is  far  less  dangerous  in  these  antiseptic 
days  than  subcutaneous  surgery.  After  the  section, 
and  the  wound  has  been  properly  dressed,  the  head 
may  be  retained  in  position  by  a  plaster  of  Paris 
bandage.  Should  subsequent  elastic  traction  be  re- 
quired, the  apparatus  of  Sayre  is,  in  my  judgment, 
the  simplest  and  most  satisfactory.      It  consists  of  a 


272  PRESENT    STATUS    OF    PEDIATRICS. 

rubber  band  which  is  attached  to  a  piece  of  plaster 
around  the  forehead  and  to  a  band  around  the  oppo- 
site shoulder. 

SCOLIOSIS. — Scoliosis,  or  lateral  curvature,  is  a 
deformity  in  which  there  is  a  deviation  of  the  spinal 
column  in  a  lateral  direction.  It  is  the  most  common 
of  all  orthopedic  diseases,  and  most  frequent  between 
the  ages  of  eight  and  fifteen  years. 

Causes. — The  causes  may  be  considered  under  the 
following  headings :  First,  rhachitic  ;  second,  static  ; 
third,  pathological.  By  far  the  greater  number  of 
these  cases  belong  to  some  of  the  diatheses,  and  rha- 
chitis  is  unquestionably  the  most  important.  Rha- 
chitic curvatures  are  seen  most  frequently  during  the 
first  two  years  of  life,  and  are  usually  due  to  the  habit 
on  the  part  of  the  mother  of  holding  the  child  nearly 
always  in  one  arm.  By  static  causes  we  mean  press- 
ure effects,  and  in  truth  all  cases  are  static ;  /.  e. ,  what- 
ever may  seem  to  be  the  starting  point  of  the  disease, 
the  deformity  is  always  because  of  inequality  of  pi'ess- 
iire.  Under  this  heading  comes  habitual  deviations, 
as  from  writing  at  a  desk  which  is  too  high  and  neces- 
sitates raising  the  shoulder;  tilting  of  the  pelvis, 
either  from  an  unequal  length  of  the  legs,  or  from  the 
habit  of  standing  a  great  share  of  the  time  upon  one 
leg,  etc.  Pathological  scolioses  are  not  very  common. 
Those  most  frequently  seen  are  from  empyema  and 
due  to  the  contraction  of  the  bands  of  adhesion,  and 
faulty  expansions  of  the  chest.  Others  are  due  to 
diseased  conditions  of  the  bones  or  articulations  of 
the  spine  (usually  tuberculous    and   associated  with 


ORTHOPEDIC    SURGERY.  273 

kyphosis)  and  also  to  cicatricial  contraction  following- 
extensive  destruction  of  soft  tissue. 

Pathology. — After  the  deformity  has  once  begun, 
its  perpetuation  and  increase  are  due  to  pressure  ef- 
fects. The  bones  develop  rapidly  where  the  pressure 
is  least  and  are  prevented  in  their  growth,  and  in 
some  cases  even  atrophy,  in  parts  where  pressure  is 
unusually  great.  As  a  result  we  have  the  vertebrae 
becoming  wedge-shaped,  the  base  of  the  wedge  being 
on  the  convex,  and  the  apex  on  the  concave  side  of 
the  column.  The  intervertebral  discs  are  similarly 
affected.  With  these  there  is  a  rotation  of  the  ver- 
tebrae upon  each  other,  the  bodies  turning  toward 
the  convexity,  the  spines  toward  the  concavity.  The 
rotation  is  at  times  so  pronounced  that  in  mild  curva- 
tures the  spines  seem  hardly  to  deviate  from  their 
normal  relation  to  each  other,  and  hence  the  imrelia- 
bility  of  this  symptom  in  diagnosis.  Consequent  upon 
the  rotation  of  the  spine  there  are  the  characteristic 
changes  in  the  conformation  of  the  thorax  due  to 
alteration  in  position  and  shape  of  the  ribs  at- 
tached to  the  involved  portion.  The  ribs  on  the 
convex  side  are  carried  backward  and  the  inter- 
costal spaces  widened.  This  gives  a  pronounced 
bulging  of  this  side  of  the  thoracic  wall  behind  and  a 
corresponding  depression  in  front.  On  the  concave 
side  the  opposite  condition  obtains,  the  ribs  being 
carried  forward  and  approximated.  The  typical  ob- 
lique thorax  is  the  result,  the  cavity  on  the  convex 
side  being  pronouncedly  diminished  in  all  directions, 
the  concave  side  being  diminished  only  in  the  longi- 
tudinal direction.  The  changes  in  the  muscles  and 
19 


274  PRESENT    STATUS    OF    PEDIATRICS. 

ligaments  are  in  the  main  an  adaptive  shortening  on 
the  concave  side  and  a  stretching  and  thinning  of  those 
on  the  convex  side. 

Symptoms  and  Diag-nosis. — These  of  course  de- 
pend upon  the  location  of  the  curve  and  upon  its 
extent.  In  rhachitic  cases  in  infants  the  symptoms 
are  all  objective.  The  curve  is  usually  a  dorso-lum- 
bar  one,  the  convexity  being  left  or  right  as  the 
mother  holds  the  child  mostly  on  the  left  or  right  arm. 
In  older  children  we  have  a  more  interesting  study. 
They  may  complain  of  a  general  weariness  or  tired 
feeling  for  some  weeks  before  any  spinal  trouble  *is 
suspected.  The  first  symptoms  which  usually  alarms 
the  mother  is  an  undue  prominence  of  either  the 
shoulder  or  the  hip,  depending  upon  whether  the  pri- 
mary curve  be  a  dorsal  or  a  lumbar  convexity.  In 
either  case  a  compensatory  curve  with  an  opposite 
convexity  usually  follows  within  a  few  weeks.  Most 
authors  assert  that  the  right  dorsal  convexity  is  by 
far  the  more  frequent.  My  own  observation  leads  to 
the  belief  that  the  left  lumbar  convexity  is  more 
common  than  usually  admitted.  It  is  of  the  utmost 
importance  to  the  intelligent  treatment  of  the  case 
that  the  surgeon  do  not  rest  satisfied  with  running  his 
finger  along  the  spine  and  a  diagnosis  of  scoliosis — 
to  recognize  the  primary  curve  is  imperative.  There 
is  an  asymetry  of  the  sides  of  the  body  in  both,  but 
the  following  differences  will  be  noted  upon  careful 
examination :  The  patients  should  always  be  stripped 
if  possible,  and  if  not,  one  thin  garment  only  should 
be  supported  by  a  band  around  the  pelvis  just  above 
the  great  trochanters,  thus  exposing  the  waist  line  and 


ORTHOPEDIC    SURGERY.  275 

the  iliac  crest.  In  primary  dorsal  convexity,  the  pa- 
tient standing  erect  with  the  heels  together,  the  arms 
hanging  naturally,  the  upper  part  of  the  body  seems 
to  have  been  shifted  to  the  right,  the  right  shoulder 
is  elevated,  its  scapula  prominent,  the  right  arm  hangs 
at  the  side  one  or  two  inches  away  from  the  body 
even  at  the  crest  of  the  ilium.  The  waist  line  is 
markedly  deepened,  the  right  hip  being  unduly  promi- 
nent. The  left  arm  hangs  close  to  the  body,  the 
normal  waist  line  assuming  an  elongated,  semi-lunar 
curve  from  the  iliac  crest  to  the  axilla. 

In  the  primary  left  lumbar  convexity,  the  left 
waist  line  appears  shallower  and  even  at  times  oblit- 
erated, the  arm  hanging  almost  or  quite  in  contact 
with  the  trunk.  On  the  right  side  the  waist  line  is 
considerably  deepened  and  opens  at  a  more  acute 
angle.  The  hip  becomes  more  prominent,  so  that  the 
arm  presses  closely  against  instead  of  hanging  at  a 
distance,  as  in  the  primary  dorsal  curve. 

Prognosis. — This  depends  upon  the  stage  at  which 
the  patient  applies  for  help  and  the  cause  of  the  de- 
formity. In  general,  we  may  say  that  those  cases 
where  suspension  overcomes  the  deformity  and  the 
cause  can  be  removed  or  counteracted,  will  get  well. 
Where  suspension  only  partly  overcomes  the  displace- 
ment some  improvement  may  be  promised  but  where 
the  deformity  is  fixed  and  particularly  in  aggravated 
cases  all  a  surgeon  can  do  is  to  prevent  greater  de- 
formity and  at  times  even  this  is  impossible. 

Treatment. — The  proper  treatment  depends  en- 
tirely upon  a  correct  diagnosis.  Those  who  treat  all 
cases  of  scoliosis  alike  cannot  hope  for  uniformly  good 


276  PRESENT    STATUS    OF    PEDIATRICS. 

results.  In  no  other  cases  is  equalization  of  pressure 
so  important.  In  the  rhachitic  curves  of  infants  and 
young  children  suspension  and  the  application  of  a 
plaster  of  Paris  cast  will  be  all  that  is  necessary.  The 
primary  lumbar  curvatures  are  usually  due  to  habit 
or  an  unequal  length  of  the  legs,  and,  unless  of  very 
long  duration  and  marked  compensatory  curves  have 
taken  place,  can  usually  be  corrected  by  elevating  the 
foot  of  the  convex  side.  This  may  be  done  by  a  cork 
sole  of  sufficient  thickness  to  overcome  the  deformity 
and  should  be  worn  constantly  in  cases  due  to  un- 
equal legs  and  as  long  as  necessary  in  Jiabit  cases. 
When  aggravated  compensatory  curvatures  have  taken 
place  the  braces  recommended  for  the  dorsal  curves 
must  also  be  used,  the  patient  being  placed  upon  those 
muscular  exercises  which  tend  to  improve  the  general 
health  as  well  as  to  strengthen  the  spinal  muscles. 
Primary  dorsal  convexities  are  equally  amenable  to 
treatment  in  the  earliest  stages,  when  due  to  the  as- 
sumption of  faulty  positions  and  abnormal  growth  in 
consequence.  Such  cases,  when  occurring  in  children 
up  to  ten  or  twelve  years  of  age,  where  suspension 
entirely  remedies  the  defect,  are  most  satisfactorily 
treated  with  plaster  of  Paris  casts.  In  older  children, 
and  in  more  aggravated  forms,  the  application  of  a 
Taylor  or  Stillman  brace  will  be  followed  by  the  best 
results.  The  suspension  belt,  the  rotary  and  ring 
exercises,  the  oblique  seat,  and  the  daily  attempts  at 
moderate  manual  correction  are  valual^le  adjuvants. 
The  treatment  of  the  pathological  curvature  must  of 
course  depend  upon  the  conditions,  and  space  forbids 
their  consideration. 


ORTHOPEDIC    SURGERY  277 

POTT'S  DISEASE.— Pott's  disease,  or  spinal  caries, 
has  been  definitely  proven  to  be  in  the  majority  of 
cases  a  tubercular  inflammation  affecting  the  bodies 
of  the  vertebrae. 

Causes. — These  we  may  divide  into  the  predispos- 
ing and  the  exciting.  The  predisposition  must  al- 
ways be  regarded  as  a  lessened  power  of  resistance 
on  the  part  of  the  tissues.  This  may  be  hereditary 
or  acquired.  In  either  case  it  simply  means  that  the 
tissues  furnish  a  suitable  soil  for  the  development  of 
micro-organisms.  In  the  acquired  form  the  diseases 
which  most  frequently  render  the  little  patients  sus- 
ceptible to  this  disease  are  measles,  whooping-cough, 
and  chronic  gastro- enteric  diseases.  They  all  leave 
them  poorly  nourished  and  with  catarrhal  conditions 
which  favor  the  entrance  into  the  system  of  floating 
germs.  The  exciting  cause  is  the  bacillus  tubercu- 
losis, which  gains  entrance  usually  through  the  re- 
spiratory mucous  membrane.  The  localization  in 
bone  is  nearly  always  secondary,  the  primary  focus 
being  commonly  either  in  the  lung  tissue  or  in  the 
bronchial  glands. 

Patholog'y. — Given  the  weakly  child,  given  the 
micro-organisms  in  the  circulation,  given  the  tend- 
ency of  the  child  to  injuries  and  exposure  which 
produce  such  marked  circulatory  changes,  and  we 
have  a  chain  of  evidence  which  may  easily  account 
for  the  beginning  of  the  disease.  The  localization 
takes  part  usually  in  the  rapidly  growing  layer  of  the 
body  near  the  intervertebral  cartilages.  As  the 
micro-organisms  develop,  their  influence  converts  the 
infected  cells  into  lymphoid  corpuscles  of  consider- 


278  PRESENT    STATUS    OF    PEDIATRICS. 

able  size,  and  in  Nature's  method  of  circumscribing-  a 
foreign  body  these  cells  are  surrounded  by  exuded 
white  corpuscles  and  newly  formed  connective  tissue 
cells  which  are  distributed  circularly  around  the  cells 
primarily  affected.  The  nearest  of  these  become  in- 
fected by  the  rapidly  multiplying  germs  and  are  soon 
converted  into  rings  of  lymphoid  cells,  the  central 
one  meanwhile  enlarging  and  becoming  the  typical 
giant  cell.  Other  tubercles  form  in  the  same  way, 
and  ultimately  we  have  a  well  defined  tubercular  le- 
sion, in  the  form  of  typical  granulation  tissue.  The 
secondary  changes  which  this  tubercular  tissue  may 
undergo  are  four:  First,  fibroid  induration;  second, 
caseation ;  third,  pus  formation ;  fourth,  calcification. 
Fibroid  induration  really  means  that  the  tissues 
have  overcome  the  disease  and  have  converted  a 
focus  into  a  mass  of  healthy  granulation  tissue  which 
later  becomes  organized  into  fibrous  tissue.  Casea- 
tion is  really  a  fatty  degeneration  of  the  cells,  due 
in  part  to  a  cutting  off  of  the  nourishment  by  the 
dense  infiltration  of  round  cells  and  in  part  to  the 
direct  action  of  the  micro-organisms  and  their  pto- 
maines. When  the  nourishment  brought  to  the  part 
is  insufficient  to  supply  the  germs,  they  die,  the  mass 
undergoes  the  cheesy  degeneration,  which  is  walled 
in  by  the  conversion  of  the  round  cells  into  granula- 
tion tissue.  Thus  a  tubercular  focus  may  be  effect- 
ually circumscribed  and  remain  dormant  for  months 
or  even  years.  Pus  formation  does  not  mean  that 
secondary  infection  with  pus  microbes  has  taken 
place.  It  is  simply  the  same  process  described  as 
caseation,  only  that  the  degeneration  occurs  so  rap- 


ORTHOPEDIC    SURGERY.  279 

idly  that  the  fluid  parts  of  the  degenerated  tissues 
are  not  absorbed,  but  form,  with  the  cells  and  parti- 
cles of  fibrin,  an  emulsion  which  is  termed  tubercu- 
lous pus.  Calcification  is  a  deposit  of  lime  salts  in  an 
already  caseating  focus. 

The  deformity  is  produced  by  a  sinking-  in  of  the 
anterior  segment  of  the  diseased  vertebrae,  when  so 
much  of  the  bodies  are  destroyed  that  they  can  no 
longer  bear  the  weight  of  the  superimposed  parts. 
The  intervertebral  cartilages,  the  periosteum,  and 
even  the  ligaments  are  involved  in  the  later  stages. 
As  the  anterior  parts  sink  the  spines  project  and  pro- 
duce the  characteristic  kyphosis.  This  is  usually  a 
gradually  increasing  deformity,  but  in  extensive  de- 
generations a  fall  upon  the  feet  or  buttocks  has  been 
known  to  produce  a  sudden  one.  Abscess  formation 
comes  most  frequently  where  the  process  is  rather 
rapid.  It  is  by  no  means  a  constant  accompaniment 
of  spinal  caries.  When  pus  does  form  it  burrows  in 
the  direction  of  least  resistance.  It  cannot  go  back- 
ward on  account  of  the  spine  itself.  The  anterior 
spinal  ligament  is  usually  sufficiently  thickened  and 
strong  to  prevent  extension  forward,  and  its  interver- 
tebral attachments  prevent  easy  extension  downwards. 
The  pent-up  accumulation  passes  laterally,  entering 
the  cellular  tissue  at  the  side,  and,  guided  by  the  fas- 
cias  or  muscle  sheath,  forms  the  post-pharyngeal,  the 
psoas,  or  the  lumbar  abscesses,  according  to  the  loca- 
tion of  the  disease.  When  the  disease  is  dorsal, 
counter-curves  with  the  convexity  forward  occur  in 
the  cervical  and  lumbar  regions.  These  compensa- 
tory curves  do  not  take  place  in  disease  of  the  lumbar 


28o  PRESENT    STATUS    OF    PEDIATRICS, 

region,  but  the  body  is  bent  forward,  the  degree  de- 
pending upon  the  extent  of  the  disease.  The  conse- 
quent deformity  of  the  chest,  the  pigeon  breast,  the 
approximated  ribs  and  their  projection  over  the  pel- 
vic bones  or  their  sinking  into  the  iliac  fossae,  are 
simply  mechanical. 

Clinical  History  and  Symptoms.— The  earliest 
symptoms  are  often  obscure  and  may  present  simply 
as  a  lack  of  playfulness,  the  child  becoming  easily 
tired  and  wanting  to  lie  down  more  than  is  customary. 
Too  much  stress  has  been  laid  upon  tenderness  to 
touch  and  pains  referred  to  the  peripheral  endings  of 
the  involved  nerves,  as  diagnostic  points.  The  most 
characteristic  symptom  in  the  early  stages  is  the 
rigidity  of  the  spine.  This  may  be  tested  either  by  ly- 
ing the  patient  on  his  face  and  lifting  him  up  from 
the  bed  by  his  feet  or  by  asking  the  patient  to  pick 
up  some  article  from  the  floor.  In  the  former,  if  the 
rigidity  is  not  complete,  the  movement  will  elicit  con- 
siderable pain.  In  the  latter  the  child  will  probably 
pick  up  the  article  without  even  bending  the  spine. 
All  movements  of  a  jolting  nature  are  carefully 
avoided.  With  these  symptoms,  a  careful  search 
should  be  made  for  local  tenderness  for  referred  pains, 
etc.  The  temperature  will  usually  be  found  elevated, 
though  may  be  not  more  than  from  one-half  to  one 
degree.  In  the  later  stages  we  may  have  interference 
with  motion  from  other  causes:  First,  pachymenin- 
gitis ;  second,  from  compression  of  the  cord  from  dis- 
placement ;  third,  from  pressure  of  the  cord  by  an 
abscess.     The  first  condition  is   the  one  most  com- 


ORTHOPEDIC    SURGERY.  281 

monly  seen,  the  inflammation  may  even  extend  be- 
yond the  membranes  to  the  cord  itself. 

Prognosis. — This  depends  greatly  upon  the  stage 
in  which  the  disease  is  recognized.  If  seen  before 
deformity  this  can  usually  be  prevented.  When  the 
deformity  is  slight  it  may  be  arrested,  but  when  very 
great,  and  especially  when  paralytic  symptoms  are 
present  and  the  functions  of  the  bladder  and  bowel 
impaired,  the  prognosis  is  very  grave. 

Treatment.— This  may  be  divided  into  general 
and  local.  The  general  treatment  consists  essentially 
in  nourishment,  building  up  of  nutrition.  Rest  in 
the  horizontal  position  is  the  best  treatment  in  the 
majority  of  cases  before  deformity  is  apparent.  It 
must  be  carried  out  throroughly  and  for  a  time  rang- 
ing from  six  weeks  to  as  many  months.  The  patient 
of  course  must  lie  on  a  firm  mattress  without  a  pillow 
and  should  not  be  allowed  under  any  circumstances 
either  to  sit  up  or  to  get  up.  Even  when  slight  de- 
formity is  present  this  treatment  is  most  satisfactory 
and  may  be  aided  either  by  traction  or  by  the  suspen- 
sion belt.  The  plaster  jacket,  properly  applied,  is 
perhaps  the  best  one  agent  we  have.  Those  who  de- 
cry its  value  are  the  ones  who  do  not  properly  apply 
it,  and  the  ones  who  do  not  recognize  that  it  does  not 
aim  at  complete  obliteration  of  an  existing  deformity. 
Its  object  is  simply  fixation  and  to  prevent  the  inju- 
rious effects  of  pressure.  It  should  never  be  applied 
without  suspension  to  the  extent  of  removing  all  of 
the  deformity  possible.  Verbal  descriptions  of  the 
many  braces  in  use  for  this  deformity  are  very  unsat- 
isfactory.     For  their  description  a  larger  work  must 


262  PRESENT    STATUS    OF    PEDIATRICS. 

be  consulted,  the  author  simply  stating  his  preference 
for  those  of  Stillman  and  Banning  with  Sayre's  jury 
mast  attachment  when  necessary.  Poro-plastic  felt 
moulded  over  a  plaster  cast  is  a  satisfactory  and  in- 
expensive method  of  support. 

TALIPES. — Under  talipes  (club-foot)  we  will  con- 
sider those  deformities  resulting  from  abnormal  posi- 
tions of  the  foot,  or  of  its  divisions,  in  relation  to  the 
leg  or  to  each  other. 

Causes. — Talipes  may  be  congenital  or  acquired. 
Congenital  talipes  is,  as  a  rule,  bilateral,  and  the  de- 
formity is  due  to  alteration  in  the  shape  or  position 
of  the  bones  themselves.  Acquired  talipes  is  second- 
ary in  its  nature  and  follows,  in  order  of  frequency, 
paralysis  or  muscular  contractions;  second,  diseases 
of  bones  and  joints;  third,  traumatism,  resulting  in 
fracture  or  dislocation  or  cicatrization  during  healing 
of  abraded  surfaces.  There  are  many  theories  regard- 
ing the  causes  of  congenital  talipes.  There  is  no  doubt 
in  my  own  mind  that  each  of  the  f611owing  factors 
plays  its  important  part:  First — Heredity.  Many 
families  are  afflicted  through  generations.  Second — 
Mechanical  pressure.  To  quote  from  Parker:  "The 
feet  assume  different  positions  at  different  periods  of 
intra-uterine  life,  and  any  influence  that  keeps  them 
too  long  in  any  one  position  may  be  an  efficient 
factor  in  producing  the  deformity."  Third — Defect- 
ive development,  due  to  a  primary  disturbance  in  the 
affected  bones  or  joints. 

Symptoms. — These  are  subjective  and  require  no 
attention. 

Patholog'y. — We  will  speak  more  fully  of  the  an- 


ORTHOPEDIC    SURGERY.  283 

atomical  changes  under  the  different  varieties,  but  I 
wish  to  insist  very  strongly  that  the  greatest  change 
is  not  in  the  joint ^  not  in  the  contracted  fascia  or 
tendons,  but  in  the  growth  of  bone  in  an  abnormal 
direction.  The  soft  tissues,  fascia,  muscles,  and  liga- 
ments adapt  themselves  to  altered  positions,  and,  be- 
coming fixed,  the  abnormal  contractions  assist  in  the 
perpetuation  of  the  deformity,  because  of  course  the 
growth  of  the  bone  will  take  place  most  rapidly  in 
the  direction  of  the  least  resistance  or  pressure. 

Let  us  now  divide  our  subject  and  go  more  fully 
into  the  characteristic  features  of  each  variety.  We 
will  speak  of  four  varieties  of  talipes  which  may 
occur  singly,  but  do  more  commonly  in  combination. 
These  are  talipes  equinus,  talipes  calcaneus,  talipes 
varus,  talipes  valgus. 

Talipes  equinus  is  a  deformity  due  to  abnormal 
extension  of  the  foot.  The  heel  is  drawn  upward,  the 
apex  of  the  foot  downward,  without  co-incident  lateral 
deformity.  The  foot  lies  in  a  more  or  less  straight 
line  with  the  leg,  the  patient  walking  on  the  ends  of 
the  metatarsal  bone,  or,  in  aggravated  cases,  even 
upon  the  dorsal  surface  of  the  curved  under  toes.  It 
is  commonly  associated  with  some  degree  of  varus 
and  shall  receive  attention  under  the  heading  of 
equino-varus.  Talipes  equinus  is  rarely,  if  ever, 
congenital.  The  most  common  causes  of  the  acquired 
form  are,  first,  paralysis  of  the  anterior  tibial  muscles ; 
second,  mechanical  pressure  from  prolonged  disuse 
in  the  extended  position;  third,  joint  inflammations; 
fourth,  traumatic  contracture  of  muscles  of  calf  from 
burns,  inflammations,  etc. 


284  PRESENT    STATUS    OF    PEDIATRICS. 

Symptoms. — The  symptoms  are  unmistakable ;  the 
diagnosis  easy.  The  degree  of  deformity  depends 
largely  upon  the  condition  of  the  extensor  muscles  of 
the  toes.  When  these  are  not  paralyzed,  the  deformity 
is  not  extreme ;  when  they  are,  the  patient  may  even 
walk  upon  the  dorsum  of  the  foot.  Examine  always 
with  the  leg  extended,  as  flexion  relaxes  the  posterior 
tibial  muscles  and  thus  renders  dorso-flexion  more 
easy. 

Patholog'y.  —  In  modern  cases  the  anatomical 
changes  are  those  of  malposition  rather  than  altera- 
tion in  shape  of  the  bones.  The  astragalus  is  in  con- 
tact with  the  tibia  and  fibula  only  in  its  posterior  sur- 
face; its  upper  and  anterior  surfaces  being  projected 
forward  and  appearing  as  a  marked  prominence  on 
the  dorsum.  The  scaphoid  is  displaced  downward 
and  is  sometimes  in  contact  with  the  calcaneus.  The 
calcaneum  is  lifted  up  and  back,  and  at  times  is  even 
in  contact  with  the  bones  of  the  leg  and  dislocated 
from  its  attachment  to  the  cuboid.  New  joint  sur- 
faces are  formed  and  the  exposed  cartilages  become 
absorbed.  The  metatarsal  bones  become  concave  on 
the  plantar  surfaces  and  convex  on  the  dorsal.  The 
dorsal  ligaments  are  stretched,  the  plantar  ones  con- 
tracted.  The  hollow  of  the  foot  is  markedly  deepened. 

Prognosis  and  Treatment. — In  recent  cases  the 
prognosis  is  usually  good,  but  in  long  lasting  cases, 
especially  of  the  paralytic  variety  where  nutrition  is 
at  a  low  ebb,  and  especially  where  marked  changes 
have  occurred  in  the  bones,  prolonged  treatment  is 
necessary  to  accomplish  even  fair  results.  .  Prevent- 
ive treatment  should  always  be  adopted  in  sickness 


ORTHOPEDIC    SURGERY.  285 

requiring  prolonged  rest  in  bed ;  exercise  passive  in 
character,  and  frequent  change  in  position,  is  all  that 
is  necessary.  In  infants  and  in  moderate  cases  ma- 
nipulation and  massage  will  often  effect  a  cure.  In 
severer  cases  forcible  straightening  under  chloroform 
and  with  or  without  tenotomy  of  the  tendo  achillis 
and  fixation  with  plaster  of  Paris  cast  is  my  favorite 
method  of  dealing  with  this  deformity.  In  very  mild 
cases,  elastic  or  semi- elastic  traction  (in  connection 
with  manipulation),  applied  after  the  method  of  Sayre, 
is  often  helpful.  I  shall  make  no  effort  to  describe 
the  many  forms  of  appliances.  Their  number  is  a 
sufficient  guarantee  of  inadequacy,  and  they  are  all 
built  upon  the  plan  of  elastic  traction.  Tenotomy 
shortens  the  duration  of  the  treatment  and  is  often 
demanded  in  cases  not  due  to  paralysis.  Paralytic 
cases  can  rarely  call  for  tenotomy,  for  obvious  reasons. 
The  plaster  should  not  be  applied  immediately  after  a 
tenotomy.  Allow  the  wound  to  heal  first.  Osteotomy 
or  resection  of  one  or  more  of  the  tarsal  bones  may 
be  demanded  in  severe  cases,  and  in  complicated 
ones,  section  of  fascias  and  ligaments  may  be  needed. 
Talipes  varus  is  a  deformity  due  to  abnormal 
adduction  and  inversion  of  the  foot.  The  ape::  of  the 
foot  is  directed  inward,  the  inner  border  up  and  the 
external  border  depressed  and  resting  upon  the  ground 
when  standing.  It  is  the  most  frequent  form  of 
talipes  and  is  most  often  congenital.  The  congenital 
variety  is  due  to  a  primary  change  in  the  bones ;  the 
acquired  is  nearly  always  secondary  to  paralysis, 
though  it  may  be  due  to  trauma  or  disease,  the  changes 


286  PRESENT    STATUS    OF    PEDIATRICS. 

in  the  bone  being  due  to  the  fact  that  the  growth  i^ 
restricted  in  its  normal  course  by  pressure. 

Symptoms  and  Diag'nosis. — Unless  the  deform- 
ity is  quite  marked  it  may  not  be  recognized  until  the 
baby  begins  to  walk,  as  slightly  adducted  feet  are 
natural  in  infants.  With  the  first  attempts  at  walk- 
ing, however,  the  external  border  of  the  foot  alone 
touches  the  ground.  This  tendency  the  superimposed 
pressure  aggravates,  and  as  the  development  increases, 
the  deformity  gets  worse,  the  bones  growing  in  the 
direction  where  least  pressure  is  exerted.  The  mus- 
cles and  ligaments  adapt  themselves  to  the  false  po- 
sition of  the  bone.  Callosities  and  even  bursae  may 
form  on  the  external  and  dorsal  surfaces  as  the  result 
of  pressure,  and  add  greatly  to  the  discomfort  of  the 
patient  as  well  as  to  the  difficulty  of  cure. 

Patholog'y. — In  aggravated  cases  the  bones  of  the 
foot  are  all  altered  in  shape,  the  most  marked  changes 
being  noticed  in  the  astragalus,  calcaneum,  and  cuboid. 
It  is  impossible  to  describe  fully  in  words  the  changes 
which  occur  in  the  shape  of  these  bones.  The  astrag- 
alus becomes  somewhat  wedge-shaped,  twisted,  and 
curved  with  the  concavity  on  the  plantar  and  internal 
sides.  The  calcaneum  is  also  twisted  or  rotated  in- 
ternally and  becomes  concaved  and  shortened  on  its 
inner  border,  and  its  articulations  with  both  astragalus 
and  cuboid  are  altered  in  direction  and  position.  The 
tarsal  joint  is  bent  inward,  the  dorsal  portion  being- 
directed  forward,  the  sole  backwards.  In  aggravated 
cases  the  angle  formed  between  the  foot  and  leg  is  an 
acute  one.  Marked  atrophy  of  all  the  muscles  takes 
place  from  disuse  until  the  legs  look   like  rounded 


ORTHOPEDIC    SURGERY.  287 

sticks.  In  the  combined  form,  equino-varus,  there  is 
the  drawing  tip  of  the  heel  in  addition  to  the  condi- 
tion described. 

Treatment. — The  earlier  treatment  is  resorted  to, 
the  more  satisfactory  will  be  the  result.  Even  in  the 
first  week,  if  the  deformity  is  noticed  so  soon.  The 
results  of  frequent  manipulation,  attempting  the  con- 
version of  a  supinated  and  adducted  member  into  a 
pronated  and  abducted  one  is  very  satisfactory.  I 
know  of  nothing  more  satisfying  in  the  whole  realm 
of  surgery  than  to  cure  a  case  of  marked  talipes  varus 
and  it  can  be  done  almost  without  exception  in  a  few 
weeks  by  proper  manipulations  during  the  early  weeks 
of  infancy.  The  manipulations  should  be  assisted 
by  bandages,  and  even  plasters.  In  older  children 
forcible  straightening,  either  with  or  without  tenot- 
omy, and  plaster  casts  in  rather  an  exaggerated  normal 
position,  gives  the  best  results. 

Talipes  Calcaneus. — In  this  deformity  there  is  an 
abnormal  flexion  of  the  foot  upon  the  leg,  the  sole  of 
the  foot  looking  forwards  and  the  patient  walking 
upon  the  heel. 

Causes. — The  causes  in  order  of  frequency  are, 
first,  congenital  defect;  second,  paralysis;  third, 
traumatism,  resulting  either  in  rupture  of  the  tendo 
achillis  or  cicatricial  contractions  on  the  front  of  the 
leg  or  foot. 

Symptoms  and  Diag'nosis. — These  are  self-evi- 
dent and  need  no  description.  The  differentiation  as 
to  cause  only  is  of  import. 

Patholog'y. — The  changes  are  those  of  position 
rather  than  of  form.     There  is  usually  marked  atro- 


288  PRESENT    STATUS    OF    PEDIATRICS. 

phy  of  the  muscles  of  the  calf,  which  allows  the  flex- 
ors of  the  foot  to  draw  the  toes  up  and  the  plantar 
muscles  draw  the  calcaneum  forward  and  down  and 
thus  increase  the  arch  of  the  foot. 

Treatment. — This  should  be  directed  to  raising 
the  heel  and  depressing  the  apex  of  the  foot.  The 
congenital  variety  may  be  treated  by  splints  or  plas- 
ter casting  before  patient  learns  to  walk.  When" chil- 
dren are  older  and  walk,  elastic  traction  from  a  spur 
projecting  from  the  heel  to  a  band  around  the  calf 
of  the  leg  would  act  as  a  tendo  achillis.  Operative 
measures,  such  as  shortening  the  tendo  achillis  and  of 
suturing  this  cut  tendon  to  the  severed  tendons  of  the 
peronei  muscles,  have  been  done. 

Talipes  valg'US. — In  this  deformity  the  foot  is 
everted  or  abducted.  The  inner  border  looks  down, 
the  outer  up  and  the  plantar  surface  outward. 

Causes. — This  form  is  rarely  congenital,  and  when 
so  found  is  almost  invariably  combined  with  calcaneus, 
making  talipes  calcaneo-valgus.  The  acquired  form 
is  usually  either  due  to  rhachitic  softening  of  the 
bones,  which  sink  down  under  pressure — it  is  often  as- 
sociated with  genu  valgum — or  to  prolonged  standing 
in  those  not  muscularly  strong.  The  age  usually  is 
enough  to  differentiate. 

Symptoms  and  Diagnosis.— These  are  flattening 
of  the  arch  of  the  foot,  especially  of  the  inner  border, 
the  heel  projects  posteriorly  and  the  external  border 
is  cast  upward,  the  sole  along  it  scarcely  touching  the 
floor.  The  inner  border  is  somewhat  irregular,  ow- 
ing to  the  prominence  of  the  astragalus  and  scaphoid 
in  their  twisted  position.     You  will  often  see  suddenly 


ORTHOPEDIC    SURGERY.  289 

acquired  cases  of  flat  foot  following  prolonged  walks 
or  dances.  These  cases  are  as  a  rule  very  painful. 
The  pain  may  be  due  to  a  strain  of  the  ligaments  or 
to  a  periostitis  or  arthritis.  If  young  people  com- 
plain of  being  easily  tired  upon  walking  or  standing 
and  especially  if  pains  in  the  feet  are  frequent,  always 
look  out  for  this  deformity  and  take  an  imprint  of  the 
foot.  An  early  diagnosis  in  the  acquired  form  is 
necessary  to  successful  treatment. 

Patholog'y.— The  changes  are  rather  in  relation- 
ship of  bones  and  joints  than  in  bone  changes.  The 
key-note  to  pathology  and  treatment  is  a  yielding  of 
the  calcaneo-scaphoid  ligament,  which  is  a  sling  liga- 
ment of  the  astragalus.  This  support  being  gone, 
the  astragalus  and  scaphoid  are  forced  in  and  down 
and  so  twisted  that  the  inner  borders  are  inclined  to 
be  the  resting  parts  of  the  foot.  The  astragalus  seems 
to  have  slipped  off  the  calcaneum,  the  fibula  resting 
upon  the  calcaneum  and  forming  part  of  the  joint. 
The  mobility  of  the  joints  are  markedly  interfered 
with. 

Treatment. — Preventive  treatment  following  early 
recognition  is  the  best.  In  rhachitic  cases  they  can 
at  least  be  stopped  without  further  deformity,  and 
often  benefited.  Well  developed  cases  in  children 
can  be  forcibly  corrected  and  plaster  casts  applied 
with  hope  of  lessening  the  deformity,  but  in  adults  a 
well  developed  case  is  all  but  hopeless  unless  some 
operation  on  the  bones  will  be  of  service.  Wedge- 
shaped  osteotomy  of  astragalus  is  recommended,  and 
establishing  osseous  ankylosis  of  the  astragalo-sca- 
phoid  articulation  is  also  spoken  of.       These  opera- 


290 


PRESENT    STATUS    OF    PEDIATRICS. 


tions  have  not  been  of  sufficient  frequency  to  warrant 
a  good  prognosis,  but  where  mechanical  measures  fail, 
an  attempt  may  be  made.  The  steel  or  leather  sup- 
port made  and  attached  to  the  inside  of  the  shoe  so  as 
to  support  the  arch  of  the  foot  is  the  only  satisfactory 
mechanical  treatment.  The  accurate  measurement 
is  best  secured  by  a  plaster  of  Paris  model, 

CONTRACTURES  AND  ANKYLOSES.— Ankylosis 
means  partial  or  complete  pathological  fixation  of  a 
joint.  Ankylosis  may  be  fibrous,  bony,  or  intra  or 
extra  articular. 

Causes. — Ankylosis  is,  in  most  cases,  the  result  of 
inflammation,  in  a  few  is  due  to  impaired  nutrition, 
and  in  still  fewer  to  cicatricial  contractions  during  the 
healing  of  the  soft  parts  and  to  fractures  into  joints. 
Fibrous  ankylosis  may  be  due  to  adherent  fibrous  de- 
posits in  an  inflamed  synovial  membrane ;  to  erosion 
of  cartilage  and  fibrous  adhesion  of  bony  surfaces,  or 
to  an  inflammatory  softening  and  subsequent  fibrous 
infiltration  of  the  capsule,  the  ligaments,  and  the 
tendons  about  a  joint.  Bony  ankylosis  may  result 
from  osseous  deposits  in  fibrous  tissue,  but  is  more 
common  as  the  result  of  fractures  into  joints  or  direct 
union  of  the  bones  entering  into  the  joint  formations 
after  the  ulceration  or  absorption  of  the  encrusting 
cartilage. 

Symptoms. — Rigidity  of  a  joint  that  is  not  a  mani- 
festation of  hysteria  or  is  not  caused  by  muscular 
spasm  on  account  of  pain  is  the  obvious  sign  of  anky- 
losis. The  differentiation  between  the  fibrous  and 
bony  forms  is  not  always  easy  without  the  employ- 
ment of  an  anesthetic.      In  the  fibrous  form  there  is 


ORTHOPEDIC    SURGERY.  29  I 

some  movement,  though  it  may  be  slight,  usually  a 
little  pain,  and  muscular  contractility  accompanying 
motion.  In  the  bony  form  there  is  no  movement, 
no  pain,  and  absolutely  flaccid  muscles. 

Treatment. — The  treatment  will,  of  course,  vary 
with  the  nature  of  the  disease  causing  the  rigidity. 
In  fibrous  ankylosis,  as  the  result  of  a  simple  inflam- 
mation which  has  subsided,  the  patient  maybe  anaes- 
thetized and  the  adhesions  forcibly  broken  up.  Pas- 
sive movements  and  massage  of  the  joint  being  daily 
and  energetically  used  until  the  patient  can  make 
active  movements  serve  a  better  purpose.  These 
measures,  preceded  by  a  hot  bath  or  steaming,  may 
be  sufficient  without  the  forcible  rupture  of  the  ad- 
hesions in  moderately  rigid  joints. 

When  fibrous  ankylosis  has  resulted  from  an  in- 
fective inflammation,  as  a  tuberculosis  or  pyemic 
synovitis  or  arthritis,  the  possibility  of  exciting  favor- 
able conditions  for  the  development  of  latent  germs 
should  alwa3^s  be  borne  in  mind.  It  should  never  be 
done  while  any  signs  of  inflammation  still  exist,  and 
seldom  earlier  than  three  or  even  six  months  after  all 
evidence  of  inflammation  has  subsided.  The  forcible 
rupture  of  fibrous  bands  is  not  entirely  free  from  other 
dangers,  especially  in  those  cases  where  there  are 
marked  extra-articular  deposits  about  the  tendons, 
nerves,  and  ligaments.  To  avoid  the  danger  of 
rupturing  blood-vessels  and  nerves  forcible  movement 
should  always  be  first  exercised  in  a  direction  which 
relaxes  these  structures — i.  e.,  flexion.  Tenotomy 
may  be  considered,  and  some  surgeons  advise  the  dis- 
secting out  of  adherent   tendons.      Neither   method 


292  PRESENT    STATUS    OF    PEDIATRICS. 

will  be  frequently  called  for.  The  muscles  moving 
the  joint,  if  markedly  atrophied,  must  be  treated  by 
massage  and  electricity  before  the  operation,  so  as  to 
improve  their  nutrition  and  render  them  capable  of 
doing  the  work  expected  of  them.  Nor  should  such 
measures  be  discontinued  for  a  considerable  time 
afterward  if  the  best  obtainable  results  are  expected. 

In  bony  ankylosis,  if  the  limb  be  in  good  position,  no 
treatment  is  called  for,  as  this  result  is  the  best  the 
conditions  allow.  If,  for  instance,  the  elbow  is  flexed 
at  right  angles,  or  a  trifle  less,  it  should  not  be  interfered 
with ;  if  extended,  excision  is  called  for.  If  the  knee 
be  fixed  in  a  flexed  position  and  the  ankylosis  be  bony, 
it  demands  a  wedge-shaped  excision  and  fixation  in 
the  extended  position,  or  an  osteotomy  of  the  lower 
part  of  the  femoral  shaft.  Osteotomy  below  the  tro- 
chanter is  the  most  satisfactory  operation  for  anky- 
losis of  the  hip  inflexion. 

GENU  VALGUM  AND  GENU  VARUM.— Genu 
valgum  is  a  deformit)^  in  which  the  knee  deviates 
from  the  normal  line  of  the  leg  inward.  It  is  com- 
monly known  as  knock-knee. 

Causes. — Rhachitis  is  the  cause  of  most  of  the  cases 
of  genu  valgum,  whether  they  occur  in  infancy  or  in 
childhood,  but  occasionally  cases  are  due  to  paraly- 
sis, traumatism,  or  are  secondary  to  knee-joint  disease. 
In  cases  occurring  in  young  men,  occupation  plays  an 
important  role,  standing  in  faulty  positions  and  bear- 
ing the  pressure  upon  the  external  part  of  the  knee. 

Symptoms. — There  may  be  some  pain  on  the  inner 
side  of  the  knee  and  indisposition  to  stand  before  de- 
formity occurs.     The   inward    position  of   the  knee 


ORTHOPEDIC    SURGERY.  293 

and  the  outward  projection  of  the  feet,  the  leg  mak- 
ing quite  an  angle  with  the  thigh  opening  outward, 
are  characteristic.  The  deformity  may  be  of  one  or 
both  legs,  and  is  greatest  in  the  extended  position. 
It  is  quite  characteristic  of  genu  valgum  that  the  de- 
formity disappears  upon  the  complete  flexion  of  the 
knee  joint.  This  is  readily  explained  by  the  fact  that 
the  posterior  plane  of  the  articular  surface  of  the 
femur  is  unchanged.  In  extreme  cases  the  legs  cross, 
forming  an  X.  The  general  or  subjective  symptoms 
are  those  of  muscular  weakness  and  general  malnu- 
trition in  infants.  In  older  people  the  patients  may 
be  entirely  well. 

Patholog'y. — The  change  is  unquestionably  in  the 
bones,  and  the  latest  authorities  are  almost  uniformly 
of  the  opinion  that  the  greatest  change  is  the  obliq- 
uity of  the  attachment  of  the  diaphysis  with  the 
epiphysis  of  the  femur.  The  appearance  would  at 
once  indicate  a  hypertrophy  of  the  inner  condyle  of 
the  femur,  and  occasionally  this  change  has  been  dem- 
onstrated. Once  started  in  this  way  of  development, 
the  irregular  pressure  from  the  superimposed  weight 
would  perpetuate  and  increase  the  deformity  and 
cause  atrophy  of  the  articulating  cartilages  on  the  ex- 
ternal side  of  the  joint  and  hypertrophy  of  those  on 
the  internal  side.  The  affected  bones  are  abnormally 
soft  and  the  epiphyseal  ends  enlarged  and  broadened. 

Treatment. — The  tendency  is  towards  increase  in 
the  degree  of  deformity,  only  exceptional  cases,  and 
those  in  very  young  children,  showing  a  disposition 
to  become  rectified  without  treatment.  The  pro- 
gressive nature  is  continuous  up  to  the  twentieth  year. 


294  PRESENT    STATUS    OF    PEDIATRICS, 

the  time  when  the  epiphysis  and  diaphysis  become 
united,  and  at  this  time,  the  bones  being  consolidated, 
the  deformity  becomes  permanent.  The  treatment 
is  most  effective  the  earlier  it  is  instituted.  In  in- 
fants operative  measures  are  rarely  called  for  in  pri- 
vate practice  where  the  patients  can  have  your  indi- 
vidual care.  Gradual  manual  correction  and  massage 
give  the  best  results.  Forcible  straightening  should 
never  be  done  in  this  deformity,  as  the  external  lat- 
eral ligament  is  apt  to  be  seriously  injured.  In  pa- 
tients unwilling  to  submit  to  operative  treatment  it 
is  best  to  use  elastic  traction  by  means  of  a  long  ex- 
ternal splint  fastened  firmly  at  the  ankle  and  at  the 
pelvis  and  the  traction  made  at  the  knee-joint.  The 
pressure  is  thus  removed  from  the  external  condyle, 
which  is  allowed  to  grow.  A  double  splint,  connected 
by  a  cross-piece  at  the  bottom  and  firmly  fastened  at 
the  waist  and  ankle,  is  suitable  where  both  legs  are 
involved.  For  a  description  of  the  many  steel  in- 
struments devised  for  the  correction  of  this  deformity, 
a  glance  at  the  cuts  in  surgical  text-books  will  tell 
more  than  a  word  picture.  Many  of  them  are  excel- 
lent, but  expensive,  and  no  more  satisfactory  in  their 
effects  than  the  more  simple  methods  already  de- 
scribed, except  that  patients  may  be  up  and  about. 
Where  instruments  fail  or  where  the  deformity  is  too 
great  for  gradual  correction,  and  especially  in  those 
cases  where  the  bone  is  sclerosed,  osteotomy,  either 
linear  or  wedge-shaped,  is  the  proper  treatment. 
There  are  many  methods,  but  for  most  cases  the  linear 
osteotomy  of  the  lower  part  of  the  shaft  of  the  femur 
through  an  external  inch  incision  is  sufficient. 


ORTHOPEDIC    SURGERY.  295 

Genu  varum  is  a  deformity  in  which  the  knees 
deviate  outward  from  the  normal  line  of  the  leg.  The 
deformity  is  scarcely  ever  in  the  joint  itself,  but  is 
due  to  a  bending  of  the  femur  or  tibia,  or  both. 

Causes. — The  cause  is  in  most  cases  rhachitis,  the 
bones  simply  showing  an  increase  in  their  normal 
curves  due  to  the  superimposed  weight. 

Symptoms. — The  S5^mptoms  are  all  objective. 
Genu  varum  of  one  side  with  genu  valgum  of  the 
other,  or  an  anterior  and  somewhat  angular  curvature 
of  the  tibia,  may  be  added,  making  an  extremely  dif- 
ficult and  awkward  gait  in  walking. 

Pathology. — The  anatomical  changes  are  those 
already  described  in  rhachitis,  and  differ  in  different 
cases,  depending  upon  whether  the  femur  or  the  tibia 
is  mostly  involved.  When  the  femur,  you  may  note 
a  gradual  curve  in  the  full  length  of  the  bone,  but 
most  commonly  the  change  is  in  its  lower  part,  the 
line  of  the  knee-joint  extending  obliquely  from  within 
down  and  out,  showing  a  development  at  the  expense 
of  the  internal  condyle  due  to  irregularity  in  the  de- 
velopment at  the  epiphyseal  cartilage.  When  the 
tibia  only  is  involved,  the  change  is  generally  great- 
est at  its  upper  third,  but  in  severe  cases  extends  for 
its  whole  length.  In  either  case  the  joint  structures 
are  interfered  with,  the  internal  ligaments  contracted 
and  tense,  and  the  external  ones  stretched  and 
thinned. 

Treatment. — When  first  noticed  in  children  begin- 
ning to  walk,  preventive  measures  while  the  child  is 
undergoing  systematic  general  treatment  is  ver}^  sat- 
isfactory.     Keep  them  oft'  their  feet  to  overcome  the 


296  PRESENT    STATUS    OF    PEDIATRICS. 

effects  of  pressure.  In  mild  cases  in  the  very  young, 
manipulation  and  massage  is  sufficient.  Later,  or  in 
more  evident  cases,  manual  correction  and  fixation 
are  called  for.  Personally  I  am  opposed  to  the  many 
forms  of  apparatus  where  simple  means  are  so  effect- 
ive. As  a  means  of  gradually  overcoming  the  de- 
formity nothing  answers  better  than  a  well  padded 
internal  splint  firmly  fixed  well  above  and  below  the 
knee  and  the  traction  of  an  elastic  or  semi-elastic 
bandage  used  to  straighten  the  bent  bones.  Forcible 
straightening  under  anesthesia  and  retention  by 
plaster  casting  is  my  favorite  method  of  dealing  with 
these  cases  where  the  rhachitic  process  is  not  cured 
and  the  bones  markedly  sclerosed.  Protection  of  the 
ligaments  of  the  knee  and  hip  is  imperative  during 
the  operation.  The  deformity,  unless  great,  can  usu- 
ally be  corrected  in  one  sitting,  a  cast  of  sufficient 
firmness  to  prevent  recurrence  applied  and  allowed 
to  remain  for  four  to  six  weeks  if  no  indications  arise 
for  removal.  Meanwhile  energetic  remedial  meas- 
ures for  rhachitic  tendencies  should  be  carried  out. 
In  markedly  sclerotic  cases  linear  osteotomy  of  the 
tibia,  preferably  with  a  chisel,  should  be  performed 
and  the  parts  dressed  in  splints  (suitable  for  a  simple 
fracture)  after  careful  reduction  of  the  deformity. 
The  section  would  be  of  course  on  the  inner  side. 
When  you  have  rhachitic  curvatures  of  the  diaphysis, 
either  in  addition  to  or  separate  from  these  deformi- 
ties of  the  knee-joints,  the  treatment  is  much  the 
same.  The  most  common  is  the  anterior  and  angu- 
lar curve  of  the  tibia  in  its  lower  third.  This  makes 
an  extremely  ugly  and  awkward  deformity  and  ne- 


ORTHOPEDIC    SURGERY.  297 

cessitates  an  acquired  flat  foot,  that  the  patient  may 
walk  at  all.  This  condition  may  usually  be  corrected 
by  the  hands  under  anaesthesia  and  suitable  splints 
applied  in  yotmg  children.  After  sclerosis  has  taken 
place,  either  linear  or  wedge-shaped  osteotomy  is 
necessary.  One  can,  as  a  rule,  promise  good  result 
by  operative  measures,  but  where  both  limbs  are  in- 
volved it  is  better  to  do  the  operations  at  separate 
times,  as  there  is  some  danger  of  fat  embolism  and 
death.  The  apparatuses  for  the  mechanical  correc- 
tion of  this  form  of  deformity  are  unsatisfactory. 
The  deviations  of  the  femur  shaft  are  not  open  to 
treatment,  unless  so  severe  as  to  render  the  patient 
helpless,  then  the  osteotomy  may  be  undertaken.  As 
the  patient  grows  these  angularities  sometimes  disap- 
pear even  without  treatment,  but  Nature  is  not  a  good 
surgeon,  and  it  is  better  to  advise  mechanical  meas- 
ures early  rather  than  to  wait  for  uncertainties. 


298  PRESENT    STATUS    OF    PEDIATRICS. 


CHAPTER  XV. 


STATISTICS. 

BY  GEORGE  B.  PECK,  M.  D.,  PROVIDENCE,  R.  I. 

In  General. — In  order  to  determine  accurately  the 
benefit  derived  by  children  from  medicaments  ad- 
ministered homoeopathically  rather  than  antipathi- 
cally  or  allopathically,  necessitates  the  comparison  of 
records  covering  a  considerable  number  of  years. 
Moreover,  the  institutions  wherein  the  various  dis- 
eases occurred  should  have  been  subject  to  identical 
climatic  and  hygienic  conditions,  and  citations  from 
their  reports  should  embrace  identical  periods  of  time. 
None  of  these  conditions  have  been  fulfilled  in  the 
following  comparisons,  because  it  has  been  simply  im- 
possible to  obtain  on  demand  what  was  desired  and 
what  may  hereafter  be  secured. 

The  Protestant  Half  Orphan  Asylum  in  New  York 
City  contributes  exact  statistics  covering  a  little  more 
than  thirty-one  years,  those  from  1842  to  1852  having 
been  recorded  by  Drs.  Clark  Wright  and  B.  F.  Bow- 
ers, and  those  from  1874  almost  to  the  present  mo- 
ment by  Dr.  A.  M.  Woodward.  The  number  of 
deaths  and  their  causes  during  the  intervening  twenty- 
two  years  have  been  noted  in  the  annual  reports  of 


STATISTICS.  299 

the  Asylum,  but  as  no  detail  of  the  cases  of  illness  is 
known  to  exist,  the  information  that  has  been  trans- 
mitted is  comparatively  useless.  The  Providence  (R. 
I.)  Children's  Friend  Society  has  registered  all  serious 
and  epidemic  cases  that  have  occurred  at  its  home 
(popularly  known  as  the  ' '  Orphan  Shelter  "),  on  Tobey 
street,  for  the  last  twenty-three  years.  Upon  the 
testimony  of  these  two  institutions  we  must  perforce 
rest  our  case  at  least  for  the  present. 

Diphtheria  is  unquestionably  the  most  serious  dis- 
order that  prevails  among  children.  The  Asylum 
reports  twelve  cases  without  fatal  result  in  the  first 
decade ;  none  have  occurred  during  the  present  ad- 
ministration. The  Shelter  reports  102  cases  with 
three  deaths,  a  mortality  of  2.94  per  cent.  One  epi- 
demic of  forty  cases  was  cared  for  without  loss  by 
Emily  Metcalf  Thurber,  M.  D.,  admitted  to  the  In- 
stitute at  its  last  session.  Her  success  led  profes- 
sional rivals  to  question  her  diagnosis,  so  she  invited 
Charles  Value  Chapin,  M.  D.,  superintendent  of 
health,  to  inspect  the  cases.  Her  vindication  was  ab- 
solute and  complete.  A  later  epidemic  of  thirty-six 
cases  was  treated  by  Henry  Mortimer  Sanger,  M.  D., 
also  a  new  member  of  the  Institute.  The  diagnosis 
in  each  of  these  was  confirmed  by  the  culture  test. 
Strickler  states  that  the  Homoeopaths  of  sixteen  cities 
reported  in  1890-92  a  loss  of  347  diphtheria  patients 
out  of  1,141,  or  30.41  per  cent,  while  the  Allopaths 
lost  2,996  out  of  8,765,  or  34.07  per  cent;  also,  that 
in  1893  the  Homoeopaths  of  eleven  cities  lost  no 
cases  out  of  376,  or  29.26  per  cent,  while  the  Alio- 


300  PRESENT    STATUS    OF    PEDIATRICS. 

paths  lost  965  out  of  2,917,  or  33.09  per  cent.  The 
most  potent  cause  of  this  great  discrepancy  between 
the  institutional  and  the  general  death-rate  is  that 
many  physicians  ivill  not  subject  their  patrons  to  the 
annoyance  of  semi-quarantine  unless  the  possibility 
of  serious  consequences  is  plainly  manifest. 

Scarlatina. — Dreaded  almost  as  much  as  the  pre- 
ceding disorder  is  scarlatina.  The  Asylum  reports 
128  cases  and  six  deaths,  4.69  per  cent.  Of  these, 
fifty-eight  were  in  the  first  decade  when  five  were 
lost  through  ensuing  drops}",  and  seventy  were  under 
the  charge  of  Dr.  Woodward,  who  saved  all  but  one. 
The  Shelter  has  had  114  cases,  with  six  deaths  also, 
5.26  per  cent.  There  were  four  distinct  epidemics; 
one  of  thirty-three  cases  treated  by  the  late  Courtland 
Hoppin,  a  member  of  the  Institute,  better  known, 
however,  as  an  artist  than  as  a  practitioner,  who  lost 
three;  another  of  eleven  cases,  with  one  death;  a 
third  of  thirteen,  with  no  death ;  and  the  fourth  of 
twenty-two,  with  one  death.  Strickler  states  that  in 
seventeen  cities  from  1890  to  1892  the  Homoeopaths 
reported  a  loss  of  157  out  of  3,039,  or  5.16  per  cent, 
while  the  Allopaths  lost  1,466  out  of  17,340,  or  8:45 
per  cent,  and  in  1893  in  ten  cities  the  Homoeopaths 
reported  693  cases,  with  30  deaths,  4.33  per  cent, 
Vv^hile  the  Allopaths  had  4,056  cases,  with  343  deaths, 
8.46  per  cent.  ^loreover,  the  following  eminent  Allo- 
pathic authorities  report  cases  as  follows:  Fleish- 
mann,  472  in  persons  under  twelve,  with  145  deaths, 
30.72  per  cent;  Kraus,  232  under  twelve,  with  43 
deaths,  18.53  per  cent;  Voit,  280  cases  under  sixteen, 


STATISTICS.  301 

with  35  deaths,  12.50  per  cent;  Roset,  287,  with  50 
deaths,  17.43  per  cent;  Resigger,  274  under  fifteen, 
with  44  deaths,  16.06  per  cent.  vStill  farther  in  the 
Manchester  (England)  Children's  Hospital  the  mor- 
tality for  ten  years,  1877-87,  was  1 1.8  per  cent,  while 
Collie  states  that  in  10,000  cases  of  all  ages  the  death 
rate  was  12.5  per  cent,  and  between  three  and  four 
25  per  cent.  These  figures,  considered  from  ^Regu- 
lar standpoint,  confirm  the  demonstration  effected  a 
score  of  years  ago  by  the  translation  and  publication 
of  Ziemssen's  Cyclopaedia,  that  in  the  little  matter  of 
restoring  the  sick  to  health  American  common  sense 
is  far  more  efficient  than  German  scholasticism. 
During  the  intervening  period  the  writer  has  failed 
to  observe  a  single  untoward  result  of  scarlatina  that 
could  not  be  traced  to  a  particular  manifestation  of 
neglect  on  the  part  of  the  person  entrusted  with  the 
care  of  the  case. 

Measles. — Of  measles  the  New  York  Asylum  re- 
ports 342  cases,  with  three  deaths  (two  from  pneu- 
monia and  one  from  acute  laryngeal  phthisis),  a  rate 
of  0.87  per  cent,  while  the  Shelter  had  129  cases,  with 
no  pronounced  evil  result.  Combining,  we  have  471, 
wdth  a  loss  of  three,  0.64  per  cent.  This  is  precisely 
the  Homoeopathic  death-rate  given  by  Strickler  for 
eight  cities  in  1890,  1891,  and  1892,  where  only  seven 
were  lost  out  of  1,098  cases,  while  the  Allopathic  loss 
for  the  same  time  and  cities  was  297  out  of  8,594,  or 
3.43  per  cent.  The  climatic  conditions  of  1893,  how- 
ever, were  unfavorable  for  those  suffering  from  this 
disorder,  for  in  nine  cities  the  Homoeopaths  lost  four- 


302  PRESENT    STATUS    OF    PEDIATRICS. 

teen  out  of  388  cases,  or  3.67,  while  the  Allopaths 
lost  302  out  of  4,385,  or  6.89  per  cent. 

Typhoid  Fever. — The  Shelter  reports  eleven  cases 
of  typhoid  fever,  with  one  death,  a  rate  of  9.09  per 
cent.  Starr  places  the  Allopathic  loss  at  from  5  per 
cent  to  14  per  cent,  according  to  the  epidemic.  In  the 
Asylum  there  were  ninety-eight  cases  of  typhus  fever 
prior  to  1852,  of  which  four  were  lost,  4.09  per  cent. 
The  agents  of  the  decedents  are  unknown.  Fifteen 
years  and  more  later,  1865-70,  the  London  Fever 
Hospital  had  734  cases  in  persons  under  ten  years, 
with  a  loss  of  twenty-five,  or  3.41  per  cent,  but  in 
187 1  had  ninety-five  cases  under  fourteen,  with  but  a 
single  death,  1.05  per  cent.  The  London  Eastern 
Hospitals  (fever)  had  191  cases,  1871-80,  in  persons 
under  fourteen,  with  but  two  deaths,  also  1.05  per 
cent.  The  Southeastern  had  twenty-six  cases  under 
ten  years  without  loss,  1880-87,  while  the  South- 
western, 187 1-80,  had  308  cases  below  fourteen,  losing 
twelve,  or  3.89  per  cent.  To  our  senior  practitioners 
these  figures  will  prove  strong  reminders  of  the  rapid 
advance  in  sanitary  science  during  the  latter  half  of 
the  ninteenth  century. 

Asiatic  cholera  attacked  forty-two  inmates  of  the 
Asylum  during  the  same  decadence  and  removed  ten, 
23. 81  per  cent.  Allopathic  mortality  is  given  as  from 
20  per  cent  to  80  per  cent,  with  an  average  of  50  per 
cent.  Naturally  cholerine  and  diarrhoea  prevailed, 
to  the  extent  of  207  cases,  none  of  which  was  fatal. 
Variola  also  called  on  fortj^-six  persons  about  that 
time,  but  removed  none.     Nineteen  were  classified  as 


STATISTICS. 


3^3 


small-pox  and  twenty-seven  as  varioloid.  The  dis- 
order had  previously  dropped  around  in  1837,  when 
it  was  under  Allopathic  control  and  removed  two  of 
the  fifteen  children  it  interviewed,  13.33  P^^  cent. 

At  divers  times  there  have  been  in  the  Asylum 
eighty-five  cases  of  pneumonia,  with  two  deaths,  a 
loss  of  2.35  per  cent.  Baginsky  observed  sixty  cases, 
one-half  in  children  under  two  years  of  age,  four  of 
which,  6.67  per  cent,  were  fatal  and  nine  were  not 
followed.  Of  dysentery  there  were  158  cases  and 
one  death,  0.63  per  cent.  Whooping'-COUg'h  abode 
with  181  children  for  a  time,  but  removed  none;  the 
Allopathic  loss  is  said  to  be  from  3  per  cent  to  15  per 
cent.  Rheumatism  removed  one  out  of  twenty-four 
subjects,  4.17  per  cent,  and  croup  one  out  of  forty- 
one,  2.39.  Moreover  34  Scases  of  mumps,  fifty- three 
of  intermittent  fever,  forty-two  of  erysipelas,  and 
forty  of  quinsy  were  treated  without  serious  result. 

It  may  be  interesting  to  note  that  in  1838  ophthal- 
mia broke  out  in  the  Asylum,  then  under  Allopathic 
control.  It  proved  an  unconquerable  scourge  to  the 
Regular  attendant,  and  his  eminent  counsel.  Dr. 
Wright,  was  called  in  to  treat  this  disorder  alone,  255 
cases  of  which  came  under  his  care.  As  he  was  uni- 
formly successful,  he  was  asked  to  prescribe  for  certain 
skin  diseases  that  had  been  raging  for  some  years  also. 
These  he  likewise  exterminated.  He  was  then  asked 
to  grapple  with  some  other  stubborn  disorder,  but 
believing  the  superiority  of  Homoeopathy  had  been 
sufficiently  established,  promptly  refused  unless  the 
entire  charge  of  the  sick  was  confided  to  him.     The 


304  PRESENT    STATUS    OF    PEDIATRICS. 

management  felt  compelled  by  his  exhibit  to  accept 
his  terms,  and  the  institution  has  remained  in  the  care 
of  the  New  ScJiool  ever  since. 

For  additional  facts  concerning  Homoeopathic  cures 
see  Transactions  of  the  American  Institute  of  Ho- 
moeopathy for  1896. 


"Malt  Extract.    This  preparation,  of  which  the  best  and  the 

best  Icnown  is  MELLIN'S  FOOD  remains  to  be  described  and  is  of 

real  value  when  used  in  combination  with  milk.     It  is  essentially 

the  same  as  UEBIG'S  SOUP,  but  so  prepared  as  to  be  marketable." 

DOMESTIC  HYGIENE  OF  THE  CHILD, 

JULIUS  UFFELMANN,  M.D. 

FOR  TPJE^     ^ 

MODIFICATION  OF 
FRESH  COWS  MILK 

USE 

Mellins  Food 

f^  Fresh  Cow's  Milfc  prepared  with 
MELLIN'S  FOOD  according  to  the 
directions,  forms  a  true  LIEBIG'S 
FOOD  and  is  the  BEST  SUBSTI- 
TUTE for  Mother's  Milk  yet  J'  J' 
produced.  J-  ^  ^  J>  J-  J*  J-  J>  J(> 

THE  DOLIBER-GOODALE  COMPANY, 
BOSTON,  MASS. 

"MELLIN'S  FOOD  is  not  only  readily  digestible  itself,  but  it 
actually  assists  to  digest  milk  or  other  foods  with  which  it  is 
mixed." 

G.  W.  WIGNER,  F.I.C.,  F.C.S., 

Pres.  Society  Public  Analysts,  London,  Eng. 


21 


HAHNEMANN 

lEDicAL  College  and  Hospital 

OF  CHICAGO. 
The  Largest  and  Best  Equipped^ * 


Homopopatliic  Medical  College  in  the  World. 

THE  THIRTY- SEVENTH  ANNUAL  SESSION 

WILL  OPEN   SEPTEMBER  ij,   1896. 

The  College  Curriculum  Embraces  the  Following  Features  : 

1.  A  four  years'  graded  Collegiate  Course. 

2.  Hospital  and  Dispensary  Clinical  Instruction  by  the  College  Staff. 

3.  Fourteen  General  Clinics  and  Sixty  Sub-clinics  each  and  every 

week  of  the  session. 

4.  Actual  Laboratory  Instruction  in  thoroughly  equipped  Labora- 

tories. 

The  buildings  are  all  new,  commodious,  and  fitted  with 
everything  which  thirty-six  years  of  experience  can  suggest. 
Heated  by  steam,  lighted  by  electricit3^  and  modern  in  every 
particular.  The  hospital  has  12  wards,  48  private  rooms,  6 
operating  rooms,  6  "foyers,"  for  convalescents,  an  emergency 
examining  and  operating  room,  reception  room,  office,  etc.,  all 
under  the  immediate  charge  of  the  College  Staff.  The  new 
College  Building  has  large,  well  equipped  Anatomical,  Physi- 
ological, Pathological,  Chemical,  Microscopical,  Biological,  and 
Bacteriological  laboratories,  cloak  room,  cafe,  smoking  room, 
ladies'  parlor,  and  toilet  rooms. 

For  announcement  and  sample  copy  of  Clinique,  address 

JOSEPH  P.  COBB,  M.  D..  Registrar . 
C   H.  l/ILAS,  M.  D.,  Dean.  2811-13  Cottage  Grove  Av. 


When  You  Go 


To  THE  .... 
Institute  Meeting 


V 


This  Year, 


Or  Any  Other  Year,  Always 
Look  Up  the  Exhibit  of  the 

/r\el9to8l7  Battery  ar^d  Optioal  <^o. 

And  see  the  new  devices  for  the  use  of  Electro-Therapeutists. 
Before  you  go,  send  for 


z::^ 


>vFmw^... 


IT  COSTS  YOU  NOTHING,  AND  WILL  AID  YOU  GREATLY. 


South^Ci^tern 
H  omoeopathiG 

^       /Tlcdical  College, 

LOUISVILLE,  KENTUCKY, 

PoR  Mbn  anl>  Wombn. 

FOUR  YEARS'  GRADED  COURSE. 


Offers  unusual  advantages  to  students  in  quest  of  a  thorough 
course  of  study. 

One-fifth  of  all  the  patients  at  the  City  Hospital,  one  of  the 
largest  hospitals  in  the  country,  are  treated  by  a  staff  appointed 
from  the  Southwestern,  and  its  students  have  thus  unrivaled 
clinical  advantages. 

Each  year  two  graduates  of  the  Southwestern  are  appointed 
internes  at  the  hospital  to  serve  one  year,  all  expenses  paid. 

For  further  particulars  and  catalogue,  write  to 

ALLISON  CLOKEY,  M.  D.,  Registrar, 

LOUISVILLE,  KENTUCKY. 
A.  LEIGHT  MONROE,  M.  B.,  Dean. 


^,  .^ 


0)  3  OJ 
C  (U-S^S  cc  ^  o 


U-l 


M-I-'  ry  Tf  HH  g  — '  .ti  !=  "^  ^  lA; ,": 


X  jj. 


THE 


Medical  Century  Library. 


^ — FIRST. — ^ 

The  Medical  Century,  a  semi-monthly  homoeopathic  journal, 
$3.00  a  year. 

AFTER  IT  THE  DELUGE! 

The  Homoeopathic  Text  Book  of  Surgery,  half  morocco,  $10; 

sheep,  $9.     By  twenty-five  of  the  foremost  surgeon-authors 

of  the  land.     (Ready.) 
Fisher's  Diseases  of  Children,  by  C.  E.  Fisher,  M.  D.    Cloth, 

$5;  sheep,  $6;  half  morocco,  $7.     (Ready.) 

PHYSICIANS'  AND  STUDENTS'  COMPENDS. 

Martin's  Manual  of  Nervous  Diseases,  by  Geo.  H.  Martin, 

]\I.  D.,  vSan  Francisco.     Muslin,  $2.     (Ready.) 
Washburne's  Manual  of  Pathology,  by  Geo.  F.  Washburne, 

M.  D.,  Chicago.     Mushn,  $2.     (In  preparation.) 
MacLachlan's  Manual  on  the  Eye,  by  D.  A.  MacLachlan, 

M.  D.,  Detroit.     ]Muslin,  $2.     (In  preparation.) 
Monroe's  Materia  Medica  Compend,  by  A.  Leight  Monroe, 

:M.  D.,  Louisville.     Muslin,  $2.     (In  preparation.) 

AND  MORE  YET! 

AS  THE  DEMAND  GROWS  OTHER  VOLUMES  WILL  BE  ADDED 
TO  THIS  SERIES. 


UNIVERSITY  ©t  CALlFUKJNiA 

AT 

LOS  ANGELES 

LIBRARY 


t 


UNIVERSITY  OF  CALIFORNIA  LIBR 

Los  Ar  »eles 
This  book  is  DUE  on  the      '  date  stam 


^^y%: 


W/-/!^  .  ww^_t_ -Sft^fisr  ^,  "^e^Tl  f  J 


k^^'Xt'' 


